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SURGICAL  TREATMENT 


GASTRIC ^niJODENAL  ULCERS 


MOYNH-IAN 


RBg'b.^ 


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Columbia  ®tttber^ft|) 


(gift  of  Ir.  ^OBtpk  A.  llakp 


Digitized  by  the  Internet  Archive 

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THE 


SURGICAL  TREATMENT  OF  GASTRIC 
AND  DUODENAL  ULCERS 


BY 


B.  G.  A.  MOYNIHAN,  M.S.  (LOND.),  F.R.C.S.  Eng., 

Senior  Assistant  Surgeon,   Leeds   General   Infirmary ;    Consulting    Surgeon    to   the    Skiptc 

Hospital  and  to  the  Mirfield  Memorial  Hospital;  Member  of  the  Board  of  Examiners 

in  Anatomy  for  the  Fellowship,  and  formerly  Arris  and  Gale  Lecturer, 

Royal  College  of  Surgeons  of  England 


1 1  lu^trai  e  d 


PHILADELPHIA,   NEW  YORK,   LONDON 

W.    B.    SAUNDERS    &    COMPANY 
1903 


THE 

SURGICAL  TREATMENT 

OF 

GASTRIC  AND   DUODENAL 
ULCERS. 


THE 

SURGICAL  TREATMENT  OF  GASTRIC 
AND  DUODENAL  ULCERS. 


In  the  following  pages  I  propose  to  discuss  my  own  experience 
in  the  operative  treatment  of  simple  ulcer  of  the  stomach  and 
duodenum,  and  to  tabulate  the  cases  upon  Mdiich  I  have  operated. 
The  subject  will  be  dealt  with  under  the  following  headings  : 

1.  Perforation  of  Gastric  or  Duodenal  Ulcers. 

2.  Hemorrhage. 

3.  Chronic  Ulcer. 

4.  Hour-glass  Stomach. 

U    PERFORATION  OF  GASTRIC  OR 
DUODENAL  ULCERS. 

The  perforation  of  a  gastric  or  duodenal  ulcer  is  one  of  the 
most  serious  and  most  overwhelming  catastrophes  that  can  befall  a 
human  being.  The  onset  of  the  symptoms  is  sudden,  the  course 
rapid,  and  unless  surgical  measures  are  adopted  early,  the  disease 
hastens  to  a  fatal  ending  in  almost  every  instance. 

Perforation  of  the  stomach  is  usually  described  as  being  of 
two  varieties,  acute  and  chronic  ;  but  there  is  an  intermediate  class 
of  cases,  not  embraced  by  either  of  these  terms,  which  is  best  de- 
scribed as  subacute. 

In  acute  perforation  the  ulcer  gives  way  suddenly  and  com- 
pletely. A  larger  or  smaller  hole  results,  and  through  this  the 
stomach  contents  are  free  to  escape  at  once  into  the  general  cavity 
of  the  peritoneum. 

In  subacute  perforation  the  ulcer  probably  gives  way  almost 
as  quickly  as  in  the  acute  form,  but,  owing  to  the  small  size  of  the 


b  .  PERFORATION. 

ulcer,  or  to  the  emptiness  of  the  stomach,  or  to  the  instant  plug- 
ging of  the  opening  by  an  omental  flap  or  tag,  or  to  the  speedy- 
formation  of  lymph,  which  forms,  as  it  were,  a  cork  or  lid  for  the 
ulcer,  the  escape  of  fluid  from  the  stomach  is  small  in  quantity 
and  the  damage  inflicted  thereby  is  less  considerable.  The  symp- 
toms at  their  onset  may  be  as  grave  as  those  in  acute  perforation, 
but  on  opening  the  abdomen  the  ulcer  may  be  seen  to  be  plugged, 
and  no  further  escape  of  fluid  is  occurring. 

In  the  subacute  form  of  perforation  I  have  found  that  there  is 
always  a  complaint  of  greater  discomfort  for  several  days  preced- 
ing the  rupture.  Vague  general  or  localized  pains  have  been  felt 
in  the  abdomen,  or  a  sharp  spasm  or  "  stitch  "  when  the  patient 
turned  quickly  or  attempted  to  laugh.  One  girl,  a  housemaid, 
felt  the  pain  down  her  left  side  especially  when  reaching  up 
to  her  work ;  another  said  that  it  hurt  her  to  bend,  as  her  side  felt 
stiff.  These  premonitory  symptoms  are  important,  and  if  recog- 
nized they  should  enable  us  to  take  measures  to  prevent  the  occur- 
rence of  perforation.  They  doubtless  have  their  origin  in  a 
localized  peritonitis,  and  the  stiffness  is  due  to  the  unconscious 
protection  of  an  inflamed  area  by  a  muscular  splint. 

In  chronic  perforation  the  ulcer  has  slowly  eaten  its  way 
through  the  stomach  coats,  and  a  protective  peritonitis  has  had 
time  to  develop  at  the  base.  The  escape  of  stomach  contents  is, 
therefore,  local  merely  ;  barriers  of  lymph  confine  the  fluid  to  a 
restricted  area,  and  a  perigastric  abscess  may  form.  A  chronic 
perforation  occurs  more  frequently  on  the  posterior  surface  of  the 
stomach,  and  the  perigastric  abscess  occasioned  thereby  is  recog- 
nized as  "  subphrenic."  The  acute  and  subacute  forms  of  per- 
forating ulcer  are  more  common  on  the  anterior  surface. 

There  can  be  no  doubt  that  recovery  by  medicinal  treatment 
alone  is  possible  both  in  the  acute  and  in  the  subacute  forms  of 
perforation.  I  have  had  two  cases  under  my  care  in  which  a 
diagnosis  of  perforation  had  been  made  by  competent  medical 
men.  In  both  an  operation  was  impossible,  as  no  skilled  help  was 
available  until  the  urgency  of  the  symptoms  seemed  to  have 
passed  off.  When  I  operated  many  months  later,  the  evidences 
of  peritonitis  completely  surrounding  the  stomach  were  undenia- 
ble.   Though  patients  may  recover,  their  recovery  cannot  be  urged 


DIFFICULTIES   OF   DIAGNOSIS.  7 

as  a  reason  for  the  delay  or  withholding  of  surgical  help  in  all 
cases.  For  the  possibility  of  spontaneous  recovery,  though  not 
denied,  is  yet  so  remote  as  to  make  it  imperative  to  adopt 
operative  treatment  at  the  earliest  possible  moment.  The  risk  of 
operation  is  definite,  the  hazard  of  delay  is  immeasurable.  There 
are  times  when  the  diagnosis  may  be  difficult.  If  morphin  has 
been  administered  to  still  the  intolerable  pain,  the  patient's  con- 
dition becomes  placid  and  comfortable.  It  may  be  almost  impos- 
sible then  to  recognize  the  extreme  urgency  of  the  case.  In  such 
circumstances  I  have,  however,  placed  great  reliance  upon  a  con- 
tinued hardness  and  rigidity  of  the  abdominal  muscles.  Even 
when  the  patient  expresses  herself  as  free  from  pain,  when  the 
aspect  has  become  natural,  and  when  the  pulse  has  returned  to 
the  normal,  the  abdominal  rigidity  remains.  In  the  case  of 
I.  S.,  a  girl  aged  seventeen,  upon  whom  I  operated  for  a  perfo- 
rated duodenal  ulcer,  the  medical  man  who  sent  her  to  the  Infirmary 
had  diagnosed  a  perforated  gastric  ulcer  and  had  told  the  patient 
and  her  parents  that  immediate  operation  alone  could  save  her 
life.  Having  obtained  consent  to  operation,  he  despatched  the  girl 
to  the  Infirmary  and  gave  a  hypodermic  injection  of  ^  gr.  morphin 
to  lessen  the  distress  of  the  journey.  When  I  saw  her,  shortly  after 
her  arrival,  she  looked  in  perfect  health,  she  had  no  suffering,  and 
her  pulse  and  respirations  were  normal.  The  abdomen,  though 
not  distended,  was  absolutely  rigid  and  immobile,  and  I  did  not 
hesitate  to  operate  at  once.  In  any  uncertain  case  I  should  incline 
to  operation  rather  than  to  indefinite  postponement  to  solve  the 
diagnosis. 

I  have  seen  a  difficulty  in  diagnosis  arise,  and  I  know  of 
three  cases  in  which  negative  exploration  had  been  performed, 
when  the  patient  was  a  woman  at  the  commencement  of  a  men- 
strual period.  From  some  unexplained  and  indeterminate  cause  a 
sharp  attack  of  abdominal  pain,  followed  by  vomiting,  distention, 
prostration,  and  collapse,  had  occurred  in  all,  and  had  caused  a 
confusion  in  the  diagnosis.  In  the  case  under  my  own  observation  a 
history  of  previous  similar,  though  less  severe,  attacks  at  the  men- 
strual epoch,  and  the  absence  of  any  marked  abdominal  stiffness 
or  tenderness,  though  the  belly  was  obviously  distended,  enabled 
me  to  negative  the  question  of  perforating  ulcer  of  the  stomach. 


8  PERFOEATION. 

A  difficulty  may  also  arise  in  the  diagnosis  of  a  perforated 
duodenal  ulcer.  In  a  paper  published  by  me  in  the  "  Lancet "  in 
December,  1901,  I  drew  attention  to  the  fact  that  in  18  cases,  out 
of  a  total  of  49  recorded,  a  diagnosis  of  appendicitis  had  been 
made,  and  an  operation  had  been  undertaken  for  that  condition. 
The  symptoms  and  signs  in  all  these  instances  had  been  limited  to 
the  right  iliac  region  or  had  been  more  accentuated  there.  This 
is  due  to  the  fact  that,  owing  to  a  hillock  in  the  transverse  meso- 
colon, under  the  pyloric  end  of  the  stomach,  extravasated  fluids 
are  directed  downward  and  to  the  right  into  the  right  renal  pouch, 
and  thence  to  the  right  iliac  fossa. 

The  operation  for  perforated  ulcer  should  be  conducted  speed- 


Fig.  1.— Diagram  showiug  the  direction  of  the  flow  of  fluid  ia  duodenal  per- 
foration. The  fluid  passes  to  the  right  Icidney  pouch  and  to  the  right  iliac  fossa, 
and  causes  the  symptoms  to  mimic  those  of  appendicitis. 

ily,  and  all  means  adopted  to  save  the  patient  from  shock.  The 
excision  of  the  ulcer  is  not  necessary.  My  practice  is  to  close  the 
ulcer  at  once  by  a  single  catgut  suture  taken  through  from  side  to 
side  so  as  to  prevent  any  further  leakage  during  the  application  of 
the  sutures.  I  apply  two  continuous  sutures  of  Pagenstecher 
thread,  which  infold  the  ulcer  and  a  portion  of  healthy  stomach 
around  it.  After  the  stitches  are  completed  the  cleansing  of  the 
peritoneum  is  begun.  If  there  is  much  soiling,  a  free  flushing  of 
the  cavity  is  necessary  ;  if  the  operation  is  done  within  ten  or 
twelve  hours,  a  gentle  wiping  of  the  surrounding  area  with  wet 
swabs  will  suffice.  Drainage,  as  a  rule,  is  not  necessary,  except 
in  the  late  cases.     When  adopted,  it  should  be  free,  a  split  tube 


MULTIPLE    PERFORATIONS.  9 

and  a  gauze  wick  being  placed  in  the  original  incision  and  in  a 
second  suprapubic  opening.  I  have  preferred  the  enlarging  of  the 
original  incision,  and  free  flushing  through  that,  to  the  method  of 
multiple  incisions  advocated  by  Finney.  One  point  I  think 
requires  emphasis  :  it  is  the  multiplicity  of  perforating  ulcers. 
As  soon  as  the  ulcer  first  discovered  is  sutured,  a  rapid  survey  of 
the  whole  stomach  is  desirable  in  order  that  any  other  ulcer  may 
be  laid  bare.  An  examination  of  a  large  number  of  recorded 
cases  has  shown  that  double  perforation  occurs  in  no  less  than  20 
per  cent.  In  the  majority  the  second  ulcer  was  on  the  posterior 
surface  at  a  point  exactly  apposed  to  the  first.  In  duodenal  ulcer- 
ation the  perforation  may  be  very  large  ;  the  ulcer  seems  to  have 
fallen  out  bodily.  When  the  gap  is  stitched  up,  a  narrowing  of 
the  caliber  of  the  duodenum  results,  and  it  may  therefore  be  neces- 
sary to  give  an  alternative  route  from  the  stomach  by  performing 
gastro-enterostomy. 


2.    HEMORRHAGE. 

The  bleeding  from  gastric  or  duodenal  ulcers  is  recognizable 
either  as  hematemesis  or  as  melena.  In  lesser  degree  these  symp- 
toms are  seen  not  infrequently ;  in  their  severer  forms  they  are  of 
dire  significance,  and  may  be  the  sole  cause  of  the  patient's  death. 
It  is  but  rarely  that  the  surgeon  is  called  upon  for  so  momentous  a 
judgment  as  is  necessary  in  cases  of  severe  hematemesis  or  severe 
melena.  For  the  condition  of  the  patient  is  poor — even,  at  times, 
desperate.  Operative  intervention  is  therefore  hazardous ;  yet  a 
continued  bleeding  will  inevitably  end  in  death.  The  question  as 
to  the  conditions  under  which  surgical  treatment  is  prudent  or 
imperative  is  one  that  has  interested  me  deeply,  and  as  my  oppor- 
tunity for  seeing  extreme  examples  of  hemorrhage  and  of  deciding 
upon  the  treatment  has  been  large,  I  may  briefly  state  my  position 
and  the  reasons  for  my  action. 

It  is  necessary  at  the  outset  to  emphasize  the  fact — a  fact  fre- 
quently ignored — that  hemorrhage  may  manifest  itself  under  en- 
tirely different  circumstances  in  different  patients.  In  some  it  is 
the  earliest  and  for  a  time  the  only  symptom  of  gastric  disturbance  ; 
in  others  it  is  the  last  expression  in  a  long  and  tedious  course  of 
symptoms.  In  other  words,  the  hemorrhage  may  occur  from  an 
aaide  or  from  a  chronic  ulcer  of  the  stomach  or  duodenum.  It  will 
be  found  when  the  clinical  history  of  a  series  of  cases  is  examined 
that  whereas  in  the  latter  the  bleeding  varies  within  the  widest  limits 
as  regards  both  quantity  and  frequency,  in  the  former  the  clinical 
history  is  repeated  in  case  after  case  in  a  most  remarkable  manner. 

Hemorrhage  from  an  Acute  Ulcer. — Under  the  term  '^  acute 
ulcer''  of  the  stomach  are  probably  included  several  varieties  of 
pathologic  conditions  which  are  different  iu  causation,  different  in 
destiny,  but  alike  in  the  single  fact  that  their  clinical  recognition 
is  due  to  the  bleeding  which  occurs  from  them  in  abundant  quan- 
tity. There  is  the  ordinary  peptic  ulcer ;  there  is  the  minute  ero- 
sion, barely  recognizable  even  on  close  scrutiny,  which  opens  up  a 

11 


12  HEMORRHAGE. 

vessel ;  and  there  are  "  weeping  patches  "  and  "  villous  areas  "  and 
similar  indetermiate  conditions  which  have  been  recognized  when 
the  stomach  has  been  explored  during  life.  To  the  clinician  all 
these  conditions  are  betrayed  by  their  tendency  to  hemorrhage. 

In  almost  every  instance  the  hemorrhage  is  the  first  symptom. 
Even  on  close  inquiry  it  is  difficult  to  elicit  any  history  of  ante- 
cedent gastric  discomforts.  The  vomiting  of  blood  comes  unex- 
pectedly and  suddenly,  a  large  quantity  of  blood  is  lost,  and  the 
patient  suffers,  often  in  an  extreme  degree,  from  the  symptoms 
of  hemorrhage.  The  pulse  becomes  feeble  and  fluttering,  the  face 
waxen,  the  breathing  rapid  and  shallow,  the  body-surface  cold  or 
clammy.  For  a  time  the  symptoms  may  give  rise  to  serious  alarm, 
but  a  rally  is  seldom  long  delayed.  The  bleeding  is  checked  spon- 
taneously, and  vomiting  is  rarely  repeated,  or,  if  repeated,  the  quan- 
tity of  blood  lost  is  but  small. 

In  several  of  my  cases  a  sudden,  apparently  causeless  hemor- 
rhage has  ushered  in  a  long  train  of  symptoms  of  dyspepsia.  The 
acute  ulcer  has  been  the  precursor,  or  rather  the  earliest  stage,  of 
a  chronic  ulcer. 

The  chai"acteristics  of  hemorrhage  from  an  acute  gastric  ulcer 
are,  therefore  :  spontaneity,  abruj^tness  of  onset,  the  rccpid  loss  of  a 
large  quantity  of  blood,  the  marked  tendency  to  spontaneous  cessation, 
the  infrequency  of  a  repetition  of  the  hemorrhage  in  anything  but  trivial 
quantity,  and  the  transience  of  the  resulting  anemia. 

Hemorrhage  from  a  Chronic  Ulcer. — The  bleeding  from  a 
chronic  ulcer  of  the  stomach  or  duodenum  may  vary  within  the 
widest  limits  of  both  frequency  and  quantity.  For  convenience  of 
description  I  should  arrange  the  cases  in  four  groups. 

1.  In  the  first  the  hemorrhages  are  latent  or  concealed.  The 
blood  lost  is  small  in  quantity,  and  may  be  recognized  only  after 
minute  examination  of  the  stomach  contents  or  of  the  feces.  The 
estimates  given  by  various  writers  as  to  the  occurrence  of  hemor- 
rhage in  ulcer  vary  between  20  per  cent,  and  80  per  cent.,  and  we 
are  entitled  to  assume  that  this  wide  divergence  of  statement  is  due 
not  so  much  to  differences  in  the  symptoms  of  ulcer,  but  rather  to 
the  varying  degrees  of  closeness  with  which  the  cases  are  observed, 
and  to  differences  in  the  frequency  and  minuteness  of  examination 
of  the  stomach  contents  or  the  feces.     It  would  probably  not  be 


INTEEMITTENT    HEMORRHAGES.  13 

rash  to  assume  that  all  ulcers  of  the  stomach  or  duodenum  bleed 
at  some  time  or  other ;  but  if  the  bleeding  be  trivial  and  infre- 
quently repeated,  it  is  never  likely  to  obtain  clinical  recognition. 

2.  In  the  second  group  should  be  included  those  cases  which 
are  characterized  by  intermittent  hemorrhage.  The  bleeding  is 
copious  but  transient,  and  occurs  at  intervals  of  two,  three,  or 
more  months.  An  exemplary  instance  of  this  class  is  the  fol- 
lowing : 

A.  S.,  female,  aged  twenty-eight.  In  May,  1898,  the  patient 
had  a  sudden  attack  of  profuse  bleeding  from  the  stomach.  She 
was  in  bed  six  weeks.  For  eighteen  months  after  this  her  health 
was  very  poor ;  indigestion  was  constant,  vomiting  was  occasional, 
constipation  was  invariable.  For  six  months  she  was  then  in 
fairly  good  health,  and  was  able  to  take  food  much  better.  In 
April,  1900,  indigestion  became  severe,  and  a  copious  hemorrhage 
again  occurred.  Treatment  was  continued  for  six  months  with 
much  benefit.  In  January,  1902,  a  third  attack  of  hematemesis 
and  fainting  ;  after  this  she  was  kept  in  bed  for  four  weeks.  In 
September,  1902,  there  was  again  hematemesis  as  severe  as  before. 
From  then  to  January,  1903,  she  was  under  constant  treatment, 
but  improvement  was  very  slow.  Anemia  has  been  a  prominent 
symptom  since  April,  1900.  At  the  operation  a  large  ulcer  was 
found  in  the  stomach,  and  a  second  in  the  duodenum.  Gastro- 
enterostomy was  performed. 

In  all  the  cases  in  this  group  indigestion  is  a  prominent  symp- 
tom. The  hemorrhage  often  occurs  without  apparent  cause,  but 
at  times  there  may  have  been  noticed  an  exacerbation  of  gastric 
discomfort  and  uneasiness  for  a  few  days.  Anemia  is  almost 
constant. 

3.  In  the  third  group  the  cases  are  characterized  by  hemor- 
rhages which  are  rapidly  repeated  and  on  all  occasions  abundant. 
In  the  majority  of  patients  the  symptoms  of  indigestion,  which 
have  been  noticed  for  months  or  years  before,  have  undergone  an 
appreciable  increase  in  the  recent  days.  Then,  suddenly,  the 
hemorrhage  occurs  ;  a  large  quantity,  a  pint  or  a  pint  and  a  half, 
of  blood  is  vomited.  The  patient  may  faint  from  loss  of  blood; 
he  shows,  always,  the  general  symptoms  of  bleeding.  For  twelve 
or  twenty -four  hours  the  vomiting  ceases,  to  reappear  at  the  end 


14  HEMOREHAGE. 

of  this  time  without  apparent  cause  and  in  equal  or  greater  quan- 
tity. A  second  latent  period  is  followed  by  a  further  hemorrhage, 
and  so  the  patient  passes  into  a  condition  of  the  gravest  peril. 

No  better  example  of  this  class  could  be  cited  than  the  fol- 
lowing : 

N.  W.,  female,  aged  twenty-four.  Has  suffered  from  symp- 
toms of  gastric  ulcer,  pain,  vomiting,  and  inability  to  take  solid 
food  for  fifteen  months.  Eleven  weeks  before  admission  to  hos- 
pital all  her  symptoms  became  worse.  Vomiting  became  fre- 
quent ;  pain  was  almost  intolerable.  During  the  five  weeks  before 
admission  she  vomited  daily,  and  on  almost  all  occasions  some 
blood  came.  While  waiting  in  the  hospital  she  vomited  three 
times  in  five  days,  and  on  each  occasion  about  half  a  pint  of  blood 
came.  She  was  seriously  ill  and  very  blanched.  Pulse  112. 
The  motions  were  tarry  on  two  occasions.  At  the  operation  two 
old  scars  and  one  showing  recent  inflammation  were  seen.  Gastro- 
enterostomy led  to  perfect  recovery. 

4.  The  fourth  group  would  comprise  those  cases  in  which 
the  hemorrhage  occurs  in  enormous  quantity,  inundating  the  pa- 
tient and  leading  to  almost  instant  death.  The  opening  of  the 
splenic  artery,  the  aorta,  the  vena  cava,  or  the  pancreatico -duodenal 
vessels  allows  of  such  a  rapid  escape  of  blood  that  the  patient  dies 
as  surely  and  as  swiftly  as  if  his  carotid  or  femoral  vessels  were 
divided.  Such  cases,  fortunately,  are  rare.  In  my  own  experience 
only  one  such  example  has  occurred,  a  large  oval  opening  being 
found  in  the  splenic  artery. 

If,  then,  we  accept  the  classification  of  cases  of  hemorrhage 
from  gastric  or  duodenal  ulcer  into  four  groups  suggested,  we  may 
define  their  characteristics  as  follows  : 

1.  The  hemorrhage  is  latent  or  concealed,  is  always  trivial, 
and  often  inconspicuous. 

2.  The  hemorrhage  is  intermittent,  but  in  moderate  quan- 
tity, occurring  spontaneously  and  with  apparent  caprice  at  infre- 
quent intervals.  The  life  of  the  patient  is  never  in  jeopardy  from 
loss  of  blood,  though  anemia  is  a  persisting  symptom. 

3.  The  hemorrhage  occurs  generally,  but  not  always,  after  a 
warning  exacerbation  of  chronic  symptoms.  It  is  rapidly  re- 
peated, is  always  abundant,  and  its  persistence  and  excess  cause 


TREATMENT  OF  HEMOERHAGE.  15 

grave  peril,  and  will,  if  unchecked,  be  the  determining  cause  of 
the  patient's  death. 

4.  The  hemorrhage  is  instant,  overwhelming,  and  lethal. 


THE  TREATMENT  OF  HEMORRHAGE. 

(A)  From  an  Acute  Ulcer. — If  what  has  been  said  of  the 
characteristics  of  hemorrhage  ftpm  an  acute  ulcer  proves  to  be 
true,  it  is  clear  that  the  aid  of  the  surgeon  will  rarely  need  to 
be  invoked.  Medicinal  means  alone  will  suffice  in  almost  every 
instance  to  insure  the  recovery  of  the  patient.  Though  the  hem- 
orrhage is  alarming  from  its  suddenness  and  intensity,  it  may  con- 
fidently be  predicted  that  in  the  majority  of  cases  it  will  not  recur, 
or  that  if  it  recur,  the  quantity  lost  will  certainly  be  small. 

There  are,  however,  a  few  cases  in  which  the  hemorrhage  may 
be  both  copious  and  recurring  and  may  threaten  the  life  of  the 
patient.  Under  such  circumstances  an  operation  may  be  re- 
quired. An  examination  of  the  recorded  cases  has  convinced  me 
that  wherever  surgical  treatment  is  deemed  advisable,  gastro-enter- 
ostomy,  speedily  performed,  will  prove  the  surest  means  of  lead- 
ing to  the  arrest  of  the  bleeding.  In  not  a  few  records  one  reads 
that  the  whole  surface  of  the  mucosa  seemed  to  be  "  weeping  " 
blood,  that  multiple  points  of  oozing  appeared  scattered  irregu- 
larly over  the  stomach  wall,  or  that  a  definite  source  of  the  blood, 
any  point  from  which  the  blood  chiefly  ran,  could  not  be  ascer- 
tained. The  surgeon  has  then  fallen  back  upon  styptics  or  the 
cautery,  or  the  ligating  of  a  villous  patch  in  mass.  It  is  diffi- 
cult to  convince  one's  self  that  any  of  these  procedures  have  had 
the  smallest  effi^ct  for  good  ;  and  in  some  the  bleeding  has  re- 
curred after  the  operation  and  has  determined  the  fatal  issue. 
A  search  for  a  bleeding  point  is  futile,  harmful,  and,  in  my  judg- 
ment, quite  unnecessary.  The  performance  of  gastro-enterostomy 
will  prove  more  effective  than  any  other  procedure  both  in  check- 
ing the  hemorrhage  and  in  preventing  its  recurrence. 

(B)  From  a  Chronic  Ulcer. — It  is  mainly  in  regard  to  the 
cases  included  in  Group  3  of  the  classification  given  above  that  the 
question  of  surgical  treatment  will  arise.  If  we  picture  to  our- 
selves the  pathologic  conditions  present  in  such  a  case,  it  will  be  seen 


16  HEMOERHAGE. 

that  though  the  bleeding  may  be  spontaneously  checked  for  a  time,  it 
will  show  a  marked  tendency  to  recur.  The  base  of  the  ulcer  is,  as  a 
rule,  densely  hard,  and  the  vessel  traverses  it  like  a  rigid  pipe. 
The  vessel  is  eaten  into,  as  it  were,  by  the  ulcer,  which  erodes  one 
side,  leaving  a  ragged  hole.  Owing  to  the  stiffening  by  chronic 
inflammatory  deposit,  the  artery  is  unable  to  contract  or  retract, 
and  the  bleeding  can  therefore  be  checked  only  by  the  plug- 
ging of  the  opening  by  a  thrombus.  That  such  a  plugging  does 
occur  there  can  be  no  doubt,  for  in  one  case  I  have  seen  it  during 
life ;  on  gently  detaching  the  cloth  the  bleeding  began  at  once 
with  furious  onset.  The  tendency,  indeed,  even  in  a  chronic  ulcer 
such  as  I  have  depicted,  must  be  to  spontaneous  cessation,  for 
in  no  other  way  can  the  stopping  and  recurrence  of  bleeding 
constantly  seen  be  explained.  There  is  some  condition,  as  yet  un- 
certain, which  is  responsible  for  the  detaching  of  the  plug.  This 
condition  I  venture  to  think  is  distention  of  the  stomach,  whereby 
the  base  of  the  ulcer  is  stretched  and  the  clot  disturbed  ;  for  my 
record  of  cases  shows  indisputably  that  a  gastro-enterostomy  per- 
formed upon  a  patient  suffering  from  this  form  of  bleeding  suf- 
fices to  check  the  tendency  to  further  hemorrhage  and  permits  of 
the  speedy  healing  of  the  ulcer.  In  all  patients  so  suffering  a 
prolonged  search  for  the  ulcer  in  the  stomach  is  injudicious,  and 
the  ulcer,  when  found,  may,  as  the  result  of  firm  fusion  with 
an  adjacent  structure,  be  irremovable.  In  two  cases  I  have 
excised  the  ulcer;  in  the  first  the  ulcer  was  on  the  posterior  sur- 
face of  the  stomach,  and  to  the  opening  left  by  its  removal  I  an- 
astomosed a  loop  of  the  jejunum  ;  in  the  second  the  ulcer  lay 
on  the  anterior  surface,  near  the  lesser  curvature,  toward  the 
cardia.  In  this  I  did  not  perform  gastro-enterostomy.  In  all  the 
other  cases  that  I  have  operated  upon  I  have  not  attempted  to  deal 
directly  with  the  ulcer,  but  have  hastened  to  perform  gastro-enter- 
ostomy. Of  all  the  patients,  the  one  upon  whom  I  did  not  per- 
form gastro-enterostomy  was  the  only  one  I  lost ;  the  others 
recovered  speedily  and  without  further  sign  of  hemorrhage. 

In  some  cases  an  examination  of  the  stomach  may  reveal  two 
chronic  ulcers,  or  more,  from  each  of  which  the  blood  may  be 
coming.  To  deal  with  each  would  be  inadvisable  or  impossible. 
Cases  are  recorded,  moreover,  in  which,  after  an  ulcer  had  been 


TEEATMENT    OF    HEMORRHAGE.  17 

excised  or  ligatured  in  mass,  the  bleeding  had  recurred  and  proved 
fatal. 

In  all  cases  of  hemorrhage  from  a  chronic  ulcer,  therefore,  an 
operation  ought  to  be  performed  at  the  earliest  possible  moment. 
Search  for,  and  local  treatment  of,  the  ulcer  or  ulcers  are  not 
necessary.  A  gastro-enterostomy  will  without  doubt  prevent  a 
recurrence  of  the  hemorrhage  and  lead  to  a  rapid  healing  of  the 
ulcer  from  which  the  blood  has  come. 


3.    CHRONIC  ULCER. 

Chronic  ulcer  of  the  stomach  may  present  itself  in  great 
diversity  of  form.  In  some  the  onset  is  brusque,  a  copious 
hemorrhage  from  an  acute  ulcer  being  the  first  manifestation  of 
gastric  disease  ;  after  the  lapse  of  a  few  days  or  weeks,  howev^er, 
gastralgia,  vomiting,  and  other  symptoms  appear,  and  the  chronic 
ulcer  is  established.  In  others  the  onset  is  latent  and  the  early 
symptoms  subdued.  A  patient  may  say  that  for  several  months  a 
trivial,  vague  uneasiness  has  been  experienced,  that  would  have 
been  forgotten  but  for  the  later  accession  of  severer  symptoms. 
In  still  others  the  course  of  the  disease  may  present  very  re- 
markable intermissions.  For  several  weeks  the  symptoms  may  be 
most  marked  and  disabling,  hemorrhage  may  occur  on  one  or  more 
occasions,  but  gradually  an  improvement  is  observed,  and  after  a 
time  all  the  distress  may  rapidly  subside,  leaving  the  patient  in  good 
health.  The  appetite  may  be  restored,  and  the  body-weight  may 
increase  by  a  stone  or  even  more.  After  a  few  months'  inter- 
val a  recurrence  of  the  symptoms  is  observed,  and  all  the  details 
of  the  former  illness  are  repeated  and  fresh  hemorrhages  may  occur. 
And  so  the  history  may  be  repeated.  In  these  circumstances  the 
symptoms  are  due  perhaps  to  the  breaking  down  in  the  scar  of 
a  solitary  ulcer,  or  to  the  fresh  outbreak  of  ulcerated  patches 
in  other  parts  of  the  organ  ;  of  the  two  possibilities,  the  former  is 
certainly  the  more  frequent. 

It  is  not  necessary  to  describe  several  different  varieties  of 
chronic  ulcer,  as  is  often  done  ;  it  is  probably  more  correct  to 
say  that  chronic  ulcer  may  present  symptoms  of  different  char- 
acter in  different  individuals,  or  in  the  same  individual  under 
differing  conditions.  Thus  an  ulcer  which  is  latent  in  onset  may 
give  rise  to  bematemesis  and  may  become  latent  again,  and  so 
the  recurrence  may  continue  for  prolonged  periods.  If  the  illness 
caused  by  chronic  ulceration  persist  for  several  years,  the  patient 
may  be  reduced  to  the  very  extremity  of  weakness.      His  disease 

19 


20  CHRONIC   ULCER. 

may  then  show  close  resemblance  to  pernicious  anemia  or  to  ad- 
vanced malignant  disease  of  the  stomach. 

I  have  no  doubt  that  many  patients  who  have  died  from  sup- 
posed malignant  disease  of  the  stomach  have  suffered  from  noth- 
ing but  chronic  ulceration.  The  induration  which  a  persisting 
ulceration  may  cause  is  remarkable  both  for  its  extent  and  for  its 
extraordinary  mimicry  of  the  appearances  of  malignant  disease. 
In  some  of  my  own  cases,  and  especially  in  one  case  of  hour-glass 
stomach,  the  mass  of  inflammatory  tissue  was,  with  the  knowledge 
I  then  possessed,  absolutely  indistinguishable  by  inspection  and 
palpation  from  a  malignant  growth.  Recently,  however,  I  have 
in  doubtful  cases  been  able,  I  think,  to  distinguish  chronic  inflam- 
matory masses  by  their  perfect  smoothness  of  surface.  A  malig- 
nant growth  is  almost  always  irregular,  knotted,  nodular,  or 
"  gritty  "  on  the  surface ;  an  inflammatory  mass  is  more  smoothly 
rounded  off,  and  there  is  often  a  milky  opacity  of  the  peritoneum. 
The  frequency  with  which  carcinoma  will  develop  in  chronic 
ulcers  is  now  generally  acknowledged.  Hauser  estimated  the 
frequency  at  6  per  cent. — a  proportion  which  seems  to  me  to  be  in 
excess  of  the  truth.  In  my  own  experience  only  one  case  has 
been  recognized. 

The  pathologic  conditions  caused  by  chronic  ulceration  in  the 
stomach  are  of  great  variety.  When  marked  cicatricial  contrac- 
tion occurs,  the  viscus  is  narrowed  at  the  site  of  the  ulcer,  and  an 
hour-glass  stomach,  or  a  trifid  stomach  (Case  14,  the  only  one 
recorded  of  this  condition),  or  a  dilated  stomach  due  to  pyloric 
or  duodenal  stenosis  results.  If  the  ulcer  slowly  deepen,  a  peri- 
gastritis is  produced,  and  the  stomach  may  become  ankylosed  to 
the  abdominal  wall,  the  pancreas,  the  liver,  or  any  other  neighbor- 
ing structure.  In  all  these  conditions,  and  in  others  where  no 
warping  of  the  stomach  can  be  found,  an  inveterate  dyspepsia  is  a 
common  symptom. 

It  has  been  the  immemorial  custom  to  look  upon  dyspepsia  as 
due  chiefly,  if  not  solely,  to  deficiency  in  the  quantity  or  quality 
of  the  gastric  juice,  to  some  lack  of  adequate  power  in  the  stom- 
ach as  a  secreting  organ.  But  dyspepsia  of  the  intractable,  con- 
stantly recurring  form  is  more  often  a  matter  of  physics  than  of 
chemistry.     In  several  cases,  as  my   records  will  show,  I  have 


ETIOLOGY.  21 

operated  for  no  other  symptom  than  intolerable  dyspepsia,  when 
no  diagnosis  of  pyloric  obstruction,  hour-glass  stomach,  or  other 
mechanical  deviation  from  the  normal  could  be  made.  Yet  at  the 
operation  abundant  proof  has  been  obtained  that  there  was  an 
obvious  distortion  or  puckering  or  adhesion  at  one  part  or  another 
of  the  organ  ;  and  that  the  stomach  was  crippled  in  the  freedom 
of  its  action  by  these  after-effects  of  ulceration.  One  observation 
that  I  have  repeatedly  made  in  operating  upon  cases  of  chronic 
gastric  and  duodenal  ulcers  is  that  such  ulcers  are  often  multiple. 
If  a  well-marked  ulcer  is  found  at,  say,  the  pyloric  end  of  the 
stomach  on  the  anterior  surface,  a  second  ulcer  may  be  found  per- 
haps at  an  exactly  apposing  point  on  the  posterior  surface,  perhaps 
elsewhere  in  the  stomach.  Chronic  gastric  ulcers  are,  in  my 
experience,  rarely  solitary. 

My  own  records  of  cases  show  that  a  duodenal  ulcer  very  sel- 
dom exists  without  unmistakable  evidence  of  gastric  ulcer.  Clin- 
ical observers  have  long  appreciated  the  difficulty  in  the  discrim- 
ination of  gastric  from  duodenal  ulcers.  The  differentiation  is  of 
little  moment,  however,  for  if  a  duodenal  ulcer  is  present  we  may 
be  almost  certain  that  a  gastric  ulcer  will  also  be  found.  It  is, 
indeed,  not  unlikely  that  the  duodenal  ulcer  is  secondary  to,  and 
directly  caused  by,  the  gastric  ulcer.  For  there  are  many  reasons, 
which  need  not  be  repeated,  which  go  to  prove  that  duodenal  ulcer 
is  due  to  the  action  of  the  gastric  juice  on  the  mucous  membrane. 
The  ulcers  are  formed  most  frequently  at  the  very  beginning  of  the 
duodenum  ;  and  the  further  the  distance  from  the  pylorus,  the  less 
likely  is  an  ulcer  to  be  present.  May  it  not  be  that  the  digestion 
of  the  duodenal  mucous  membrane  is  accomplished  only,  or,  at  the 
least,  most  easily,  when  there  is  an  excess  of  free  hydrochloric 
acid  ?  And  this  condition  of  hyperchlorhydria  is  a  common,  if 
not  a  constant,  factor  at  some  stage  in  the  history  of  a  gastric 
ulcer.  The  sequence  of  events  then  would  be — gastric  ulcer, 
hyperchlorhydria,  duodenal  ulcer.  The  sensitiveness,  as  it  were, 
of  the  duodenal  mucosa  to  acid  contact  is  shown  by  the  fact, 
demonstrated  by  Pawlow,  that  the  pylorus  does  not  relax  to  allow 
of  the  passage  of  food  until  the  duodenal  contents  are  alkaline  in 
reaction.  Vomiting  is  an  inconstant  symptom  of  chronic  ulcer. 
In  the  typical  case  of  dilated  stomach  the  vomiting  is  copious  in 


22  CHRONIC   ULCER. 

quantity,  and  occurs  at  intervals  of  two  or  three  days.  The  stom- 
ach fills  slowly  till  its  capacity  is  exhausted,  and  then  an  outburst 
of  vomiting  empties  away  the  stagnant  fluids.  In  cases  of  chronic 
ulcer  without  dilatation  the  patient  may  be  rarely  troubled  with 
vomiting.  On  inquiry  it  will  be  found  that  the  abeyance  of 
this  symptom  is  due  to  self-imposed  restrictions  in  the  diet. 
Indulgence  in  food  will  often  elicit  the  latent  symptom.  In  one 
of  my  earliest  and  worst  cases  of  hour-glass  stomach  the  patient, 
who  was  in  bed  and  under  observation  in  the  hospital  for  over  a 
week,  never  vomited,  yet  the  constriction  between  the  two  pouches 
would  barely  admit  the  end  of  a  pair  of  pressure  forceps. 

The  indications  for  operation  in  chronic  ulcer  of  the  stomach 
are  of  widely  different  character.  When  the  ulcer  is  near  the 
pylorus,  a  dilated  stomach  will  probably  be  the  chief  clinical  sign; 
when  the  ulcer  is  in  the  body,  an  hour-glass  stomach  may  be 
caused ;  when  the  ulcer  is  nearer  the  cardiac  end,  gastralgia  and 
dyspepsia  may  be  the  only  indications. 

I  feel  sure  that,  speaking,  generally,  the  time  of  the  onset  of 
pain  after  food  is  some  guide  to  the  position  of  an  ulcer.  The 
nearer  an  ulcer  lies  to  the  pylorus,  the  later  will  be  the  period  of 
onset  of  the  pain,  and  vice  versa.  Some  of  the  seeming  exceptions 
to  this  rule  are  due  to  the  fact,  which  is  commonly  overlooked, 
that  multiple  ulcer  of  the  stomach  and  duodenum  is  the  rule. 
For  example,  a  patient  who  makes  constant  complaint  of  pain 
within  half  an  hour  of  food  may  be  found  at  the  operation  to  have 
a  stenosed  pyloric  antrum  due  to  ulcer.  Yet  on  examination  a 
second  ulcer  may  be  found  within  3  or  4  inches  of  the  cardiac 
orifice,  and  may  at  first  glance  be  overlooked.  Of  such  a  case  I 
have  had  personal  experience. 

The  evidences  of  old  ulceration  in  the  stomach  are  at  times 
difficult  to  discover,  A  thin,  fibrous  adhesion,  a  little  crumpling 
of  the  surface,  or  a  whitish  blot  on  the  serous  coat  may  be  all  that 
is  left  of  a  patch  of  ulceration.  When  the  stomach  is  pinched  up 
between  the  fingers,  a  little  local  thickening  may  be  felt,  or  the 
mucous  membrane  may  not,  as  it  should,  roll  away  from  the  mus- 
cular coat  on  gentle  pressure.  If  in  performing  gastro-enterostomy 
the  needle  has  to  be  passed  through  the  stomach  wall  at  the  margin 
of  an  old  ulcer,  the  different  and  greatly   increased  resistance  to 


OPERATIVE    TREATMENT.  23 

its  passage  is  ample  evidence  of  the  change  that  has  taken  place. 
Inveterate  dyspepsia  is,  in  itself,  an  ample  warrant  for  surgical 
treatment.  Cases  are  within  the  experience  of  all  in  which  pro- 
longed medicinal  treatment,  most  thoroughly  and  carefully  super- 
vised, proves  ineifective,  or,  if  temporarily  beneficial,  is  powerless 
to  ward  oiF  the  recurrence  of  dyspepsia.  In  such  cases,  be  the 
physical  signs  what  they  may,  an  operation  is  desirable,  and  in  my 
experience  abundant  justification  for  it  will  almost  always  be  found 
when  the  stomach  comes  to  be  examined. 

There  are  few  beings  so  abjectly  miserable  as  those  who  are 
the  victims  of  intractable  dyspepsia.  The  meal-time,  which  should 
be  a  delight,  is  a  time  of  despair  and  foreboding.  The  keen  relish 
of  good  food,  which  the  man  in  physical  health  should  appreciate, 
is  a  joy  unknown  or  long  forgotten  to  the  dyspeptic.  A  patient 
who  has  misery  written  in  every  wrinkle  of  a  thin  haggard  face, 
who  by  reason  of  long  suffering  and  bitter  experience  has  felt  com- 
pelled to  abandon  first  one  dish  and  then  another,  till  fluids  alone  can 
be  taken,  and  these  not  always  with  impunity  ;  a  patient,  to  say 
the  truth,  whose  life  becomes  embittered  by  the  pangs  of  a  suffer- 
ing which  he  must  inflict  upon  himself, — this  patient  will  find,  if 
a  gastro-enterostomy  be  done  for  the  chronic  ulcer  which  is  the 
source  of  all  his  trouble,  that  his  return  to  health  and  appetite  is 
at  first  almost  beyond  belief. 

Not  a  few  of  the  patients  upon  whom  I  have  operated  have 
almost  declined,  at  the  first,  to  take  solid  food,  vegetables,  pud- 
dings, pastry,  and  so  forth  that  I  have  ordered  them.  And  when 
the  meal  has  been  taken  haltingly  and  with  grave  doubt,  a  genuine 
surprise  is  expressed  that  no  disablement  has  followed.  Indeed, 
I  do  not  know  any  operation  in  surgery  which  gives  better  results, 
which  gives  more  complete  satisfaction  both  to  the  patient  and  to 
his  surgeon,  than  gastro-enterostomy  for  chronic  ulcer  of  the 
stomach. 

OPERATIVE  TREATMENT. 

In  operating  upon  chronic  ulcer  of  the  stomach  I  always  per- 
form gastro-enterostomy.  It  matters  not  where  the  ulcer  is  placed, 
a  gastro-enterostomy  will  relieve  the  symptoms  completely  and 
permanently  and  will  permit  of  the  sound   healing  of  the  ulcer. 


24  CHEONIC   ULCER. 

This  fact,  I  submit,  is  placed  beyond  dispute  by  the  series  of  cases 
I  am  able  to  record. 

At  first  sight  it  might  appear  desirable  on  all  occasions,  or  at 
all  times  when  possible,  to  excise  the  ulcer.  Such  a  course  is 
entirely  unnecessary ;  moreover,  it  is  futile.  For  I  have  already 
pointed  out  that  gastric  ulcer  is  rarely  solitary.  If  two  ulcers  are 
found,  therefore,  or  more  than  two,  it  is  not  always  possible  to  say, 
even  by  close  examination,  which  of  the  two  is  chiefly  at  fault.  To 
excise  all  the  ulcers — for  I  have  seen  a  stomach  so  scarred  that 
the  ulcers  seemed  universal — is  quite  out  of  the  question  unless  a 
partial  gastrectomy  is  performed.  But  if  the  chief  offending  ulcer 
be  excised,  gastro-enterostomy  would  still,  in  my  judgment,  be 
necessary,  for  among  the  many  cases  of  excision  of  ulcer  which  are 
recorded  there  is  not  infrequent  mention  of  little  or  no  permanent 
improvement.  In  all  cases,  therefore,  I  submit,  gastro-enteros- 
tomy, and  gastro-enterostomy  alone,  should  be  performed.  Excis- 
ion is  unnecessary,  often  impossible,  always  insufticient;  and  is, 
therefore,  not  to  be  commended. 

On  three  occasions  I  have  performed  pyloroplasty.  The  oper- 
ation is  one  which,  both  from  its  ingenuity  and  its  immediate  suc- 
cess, appeals  strongly  to  the  surgeon.  It  is,  however,  unreliable, 
a  return  of  the  symptoms  being  not  seldom  observed.  Of  my 
three  patients,  one  remains  perfectly  well;  the  second  is  better,  but 
is  certainly  not  in  such  good  health  as  the  average  case  of  gastro- 
enterostomy ;  the  third  showed  a  speedy  return  of  all  the  symptoms, 
and  I  then  performed  gastro-enterostomy  with  a  perfectly  satis- 
factory result.  In  this  last  case  and  in  others  which  I  have  seen 
the  return  of  the  symptoms  seemed  to  be  due  in  part  to  a  narrow- 
ing at  the  site  of  the  pyloroplasty,  and  in  part  to  the  formation  of 
widespread  and  tough  adhesions  around  the  pyloric  portion  of  the 
stomach, — adhesions  which  have  seriously  hampered  the  stomach  in 
its  freedom  of  action.  Pyloroplasty  is,  in  my  judgment,  an  uncer- 
tain operation,  and  its  results  cannot  compare  with  those  seen  after 
the  operation  of  gastro-enterostomy. 

In  the  performance  of  gastro-enterostomy  I  have  made  the 
anastomosis  on  the  anterior  and  on  the  posterior  surface,  and  I 
have  used  the  Murphy  button  and  Laplace's  forceps  as  aids  to  the 
operation.     I  wish  to  speak  gratefully  of  the  help  I  have  received 


SIMPLE    SUTURE    IN    GASTRO-ENTEROSTOMY,  25 

from  these  instruments ;  but  the  greatest  service  they  have  rendered 
me  is  to  convince  me  that  they  are  entirely  unnecessary.  No 
better  anastomosis  is  possible  than  that  made  with  the  simple 
suture,  none  is  so  safe,  none  so  adaptable,  and  so  far  as  speed  is 
concerned  I  am  content  to  abide  the  decision  of  the  timekeeper. 
With  the  simple  suture  a  gastro-enterostomy  rarely  takes,  from 
the  beginning  of  the  incision  to  the  last  skin  suture,  more  than 
thirty  minutes,  and  I  have  once  completed  the  operation  in  seven- 
teen minutes.  I  mention  these  times  because  I  think  the  question 
of  pace  is  important.  Speed  is  essential,  haste  is  often  disastrous  ; 
the  two  should  be  distinguished.  Speed  should  be  the  achieve- 
ment, not  the  aim,  of  an  operator.  His  work  must  be  thoroughly 
done ;  but  being  so  done,  then  the  quicker  it  is  done  the  better. 
I  maintain  that  no  time  is  saved  by  any  mechanical  appliances, 
and  the  operation  is  with  their  aid  less  perfect  than  it  should  be. 
I  know  the  view  which  is  held  as  to  the  Murphy  button  in  Amer- 
ica, and  I  have  nothing  but  praise  for  the  great  ingenuity  dis- 
played in  its  making.  But  not  the  most  ardent  v/ill  say  that  the 
Murphy  button  never  courts  disaster.  I  have  seen  two  patients 
operated  upon  for  intestinal  obstruction  caused  by  a  Murphy  but- 
ton used  for  gastro-enterostomy ;  in  one  case  the  button  had 
remained  for  six  years.  I  have  myself  lost  one  patient  from  per- 
foration of  a  button  used  in  the  performance  of  ileo-sigmoidostomy, 
three  weeks  after  the  operation.  Now,  by  the  method  of  suture 
which  I  adopt  for  all  forms  of  intestinal  and  gastric  anastomoses, 
there  is  no  possibility — I  speak  positively — of  present  failure  or 
of  future  mechanical  disaster.  The  suture  line  has  not  leaked  in 
one  of  my  cases ;  the  anastomosis  is  perfection.  In  one  case  of 
ileo-sigmoidostomy  performed  in  acute  obstruction  due  to  cancer 
in  the  splenic  flexure  the  patient  died  at  the  end  of  twenty-three 
and  one-half  hours.  The  anastomotic  line  was  closed  with  the 
most  minute  perfection.  I  claim  for  the  method  that  it  is  simple, 
speedy,  applicable  to  all  forms  of  anastomosis  (and  therefore  time- 
saving  in  each,  for  the  operator  is  quicker  in  a  method  he  knows 
well),  and  is  not  open  to  the  objection  that  future  troubles  are,  at 
the  least,  possible. 

The  following  are  the  steps  of  the  operation  of  gastro-enter- 
ostomy : 


26  CHRONIC    ULCER. 

The  abdomen  is  opened  to  the  right  of  the  middle  line,  and 
the  fibers  of  the  rectus  are  split.  On  opening  the  peritoneum  a 
complete  examination  of  the  whole  stomach  and  duodenum  is 
made.  The  importance  of  this  cannot  be  over-emphasized.  A  con- 
striction in  the  body  or  toward  the  cardiac  end  may  be  most 
readily  overlooked  when,  as  is  not  uncommonly  the  case,  a  marked 
constriction  at  the  pylorus,  seen  at  once,  is  ample  to  account  for  all 
the  symptoms.  Cases  of  hour-glass  stomach  which  have  been 
overlooked  at  the  operation,  and  a  futile  anastomosis  made  between 
the  pyloric  pouch  and  the  jejunum,  are  recorded  by  several  dis- 
tinguished operators,  and  the  mistake  is  an  easy  one  to  make  unless 
one  is  determined  to  examine  the  whole  of  the  stomach  in  every 
case.  The  importance  of  this  examination  of  the  whole  of  the 
stomach  has  recently  received  additional  emphasis  from  the  obser- 
vation of  a  case  upon  which  I  operated  a  few  months  ago.  I  had 
diagnosed  hour-glass  stomach,  and,  opening  the  abdomen,  a  perfect 
bilocular  stomach  at  once  was  exposed.  After  demonstrating  this 
I  remarked  that  I  always  liked  to  see  quite  up  to  the  cardia  before 
beginning  my  operation,  and,  proceeding  in  the  examination,  there 
was  revealed  another  constriction  and  another  loculus.  There 
were,  in  fact,  two  constrictions  and  three  loculi  in  the  stomach — a 
trifid  stomach.  As  soon  as  the  operator  is  satisfied  as  to  the  con- 
ditions which  exist,  the  great  omentum  and  transverse  colon  are 
lifted  out  of  the  abdomen  and  turned  upward  over  the  epigastrium. 
The  under  surface  of  the  transverse  mesocolon  is  exposed,  and  the 
vascular  arch  formed  mainly  by  the  middle  colic  artery  is  seen.  A 
bloodless  spot  is  chosen,  a  small  incision  is  made  in  the  mesocolon, 
and  the  finger  is  passed  into  the  lesser  sac.  The  opening  in  the 
mesocolon  is  then  gradually  enlarged  by  stretching  and  tearing 
until  all  the  fingers  can  be  passed  through  it.  It  is  very  rarely 
necessary  to  ligate  any  vessel.  The  hand  of  an  assistant  now 
makes  the  posterior  surface  of  the  stomach  present  at  this  opening 
(see  Fig.  2),  and  the  surgeon  grasps  the  stomach  and  pulls  it  well 
through.  A  fold  of  the  stomach,  about  three  inches  in  length, 
is  now  seized  with  a  Doyen's  clamp.  The  clamp  is  applied  in 
such  a  way  that  the  portion  of  the  stomach  embraced  by  it  ex- 
tends from  the  greater  curvature  obliquely  upward  to  the  lesser 
curvature  and  toward  the   cardia  (see    Fig.   3).     The  duodeno- 


Fig.  2. — Showing  the  posterior  surface  of  the  stomach  protruding  through  the 
aperture  made  in  the  transverse  mesocolon. 


Fig.  3. — Showing  the  oblique  application  of  the  clamp  to  the  stomach. 

27 


28 


CHRONIC   ULCER. 


jejunal  angle  is  now  sought,  and  readily  found  by  sweeping 
the  finger  along  the  under  surface  of  the  root  of  the  transverse 
mesocolon  to  the  left  of  the  spine.  The  jejunum  is  then  brought 
to  the  surface,  and  a  portion  of  it,  about  nine  inches  from  the 
angle,  is  clamped  in  a  second  pair  of  Doyen's  forceps.  The 
two  clamps  now  lie  side  by  side  on  the  abdominal  wall,  and  the 
portions  of  stomach  and  jejunum  to  be  anastomosed  are  well  out- 
side the  abdomen,  embraced  by  the  clamps.  The  whole  operation 
area  is  now  covered  with  gauze  wrung  out  of  hot  sterile  salt  solu- 
tion, the  clamps  alone  remaining  visible  (Fig.  4).     A  continuous 


Fig.  4. ^Showing  the  two  damps  in  position,  and  the  first  suture. 

suture  is  then  introduced  uniting  the  serous  and  subserous  coats  of 
the  stomach  and  jejunum.  The  stitch  is  commenced  at  the  left 
end  of  the  portions  of  gut  inclosed  in  the  clamp,  and  ends  at  the 
right.  The  length  of  the  sutured  line  should  be  at  least  two  inches. 
In  front  of  this  line  an  incision  is  now  made  into  the  stomach  and 
jejunum,  the  serous  and  muscular  layers  of  each  being  carefully 
divided  until  the  mucous  membrane  is  reached.  As  the  cut  is  made 
the  serous  coat  retracts  and  the  mucous  layer  pouts  into  the  incision. 
An  ellipse  of  the  mucous  membrane  is    now  excised  from  both 


METHOD    OF    PLACING    SIMPLE    SUTURE. 


29 


stomach  and  jejunum,  the  portion  removed  being  about  one  and 
three-fourths  inches  in  length  and  half  an  inch  in  breadth  at  the 
center.  The  stomach  mucosa  shows  a  marked  tendency  to  retract ; 
it  is  therefore  seized  with  a  pair  of  miniature  vulsella  on  each  side. 
No  vessels  are  ligated.  The  inner  suture  is  now  introduced.  It 
embraces    all    the    coats    of  the    stomach  and   jejunum,   and  the 


Fig.  5. — Showing  the  method  of  suture. 


individual  stitches  are  placed  close  together  and  drawn  fairly  tight 
so  as  to  constrict  all  vessels  in  the  cut  edges.  The  suture  begins 
at  the  same  point  as  the  outer  one,  and  is  continued  without  inter- 
ruption all  around  the  incision  to  the  starting-point,  where  the  ends 
are  tied  and  cut  short.     It  will  be  found  that  there  is  no  need  to 


30 


CHRONIC    ULCER. 


interrupt  the  stitch  at  any  point,  for  there  is  no  tendency  on  the 
part  of  the  sutured  edges  to  pucker  when  the  stitch  is  drawn  tight. 
The  clamps  are  now  removed  from  both  the  stomach  and  the 
jejunum  to  see  if  any  bleeding  point  is  made  manifest.  Very 
rarely — about  once  in  ten  cases — a  separate  stitch  at  a  bleeding 


Showing  the  method  of  suture. 


point  is  necessary.  The  outer  suture  is  now  reassumed  and  con- 
tinued around  to  its  starting-point,  being  taken  through  the  serous 
coat  about  one-sixth  of  an  inch  in  front  of  the  inner  suture.  This 
outer  stitch  is  also  continuous  throughout ;  when  completed,  the 
ends  are  tied  and  cut  short,  as  with  the  inner  stitch.     There  are 


FOUR    POINTS    IN    GASTRO-ENTEROSTOMY.  SI 

thus  two  suture  lines  surrounding  the  anastomotic  opening :  an 
inner,  hemostatic,  which  includes  all  the  layers  of  the  gut ;  and 
an  outer,  approximating,  which  takes  up  only  the  serous  and  sub- 
serous coats.  For  both  stitches  I  use  thin  Pagenstecher  thread. 
No  sutures  are  passed  through  the  mesocolon  and  stomach.  The 
gut  is  lightly  wiped  over  with  a  swab  wet  in  sterile  salt  solution, 
the  viscera  returned  within  the  abdomen,  and  the  parietal  wound 
sutured  layer  by  layer.  When  the  patient  is  replaced  in  bed,  the 
head  and  shoulders  are  supported  by  three  or  four  pillows.  The 
operation  lasts,  from  beginning  to  end,  about  thirty  to  thirty-five 
minutes,  but  can  be  shortened  by  five  or  ten  minutes  if  the  condi- 
tion of  the  patient  demands  it. 

In  connection  with  the  ojaeration  of  gastro-enterostomy  the 
following  points  are  worthy  of  attention  : 

1.  The  sterilization  of  the  mouth,  stomach,  and  jejunum. 
As  soon  as  the  patient  is  admitted  for  operation  the  preparation  of 
the  mouth  is  begun  ;  the  teeth  are  cleansed  and  brushed  frequently 
with  some  mild  antiseptic  mouth-wash  ;  all  food  given  is  liquid  and 
sterile.  The  stomach  is  washed  out  twice,  once  about  thirty-six 
hours  before  the  operation,  and  again  about  six  hours  before,  with 
tepid  boiled  water.  Calomel  is  given  forty-eight  hours  before  the 
operation. 

2.  Gloves  made  of  thin  india-rubber  and  boiled  are  worn  by 
the  operator,  assistants,  and  nurses. 

3.  The  hands  are  rinsed  in  salt  solution  during  the  operation; 
no  antiseptic  is  allowed  to  touch  the  peritoneum. 

4.  Scrupulous  care  is  taken  to  avoid  any  possible  infection 
from  the  stomach  or  jejunal  mucosa.  The  scissors  and  clips  which 
touch  the  mucous  membrane  are  at  once  laid  aside,  and  not  used 
during  the  subsequent  stages  of  the  operation.  As  soon  as  the 
mucous  membrane  suture  is  completed  the  gut  is  lightly  washed 
with  saline  solution,  and  the  hands  are  then  thoroughly  well 
cleansed. 

With  regard  to  the  after-treatment  there  is  but  little  to  say  ; 
nutrient  enemata  are  given  every  four  hours,  and  the  bowel  is 
washed  out  every  morning  with  a  pint  of  hot  water ;  no  fluid  is 
given  by  the  mouth  for  twelve  hours,  or  until  the  ether  sickness 
is  over ;  then  water  in  teaspoonful  doses  every  fifteen  minutes  is 


32  CHRONIC    ULCER. 

given,  and  the  quantity  increased  and  the  intervals  lessened  if 
sickness  is  not  aroused.  At  the  end  of  forty-eight  hours  milk  and 
a  little  pudding,  soups,  and  such  like  are  given.  By  the  eighth 
day  fish  and  minced  chicken  are  taken,  and  in  less  than  a  fortnight 
solid  food  will  be  relished.  The  patient  generally  requires  a 
caution  not  to  overeat  during  the  first  month  or  two,  for  often  the 
appetite  is  ravenous. 


4    HOUR-GLASS  STOMACH. 

By  hour-glass  stomach  (bilocular  stomach  ;  hour-glass  contrac- 
tion of  the  stomach)  is  understood  that  condition  in  which  the 
stomach  is  divided  into  two  compartments  by  the  narrowing  of 
the  viscus  at  or  near  its  center.     The  two  locnli  so  formed  may 


Fig.  7. — Hour-glass  stomach — found  post  mortem. 


be  almost  equal  in  size,  or  one,  generally  the  cardiac  pouch,  may 
be  very  much  larger  than  the  other.  In  one  instance,  Case  15,  I 
have  seen  the  stomach  divided  into  three  pouches  ;  and  in  another. 
Case  14,  a  condition  of  hour-glass  duodenum  was  associated  with 
hour-glass  stomach,  so  that  four  pouches,  two  larger  in  the  stom- 
ach, two  smaller  in  the  duodenum,  were  seen.  The  isthmus  con- 
3  33 


34 


HOUE-GLASS    STOMACH. 


necting  the  two  parts  of  the  stomac'h  is  generally  found  at  or  near 
the  middle  of  the  viscus,  but  owing  to  stasis  of  food  the  cardiac 
complement  becomes  dilated  and  is  then  much  larger,  thicker,  and 
more  capacious  than  the  pyloric.  The  pyloric  pouch  is,  however, 
not  seldom  dilated  also,  and  in  such  circumstances  a  pyloric  or 
duodenal  stenosis  will  also  be  found. 

PATHOGENY. 

Hour-glass   stomach  is  usually  described  as  being  "  congeni- 
tal "  and  "  acquired."     Of  these  forms,  the  congenital  is  said  to 


3  6 

Fig.  8. — Types  of  hour-glass  stomach  :  1,  Obstruction  near  cardiac  end  ;  2, 
cardiac  pouch  concealed  by  adhesions  ;  3,  growth  in  body  of  stomach  ;  4,  two 
pouches  connected  by  a  narrow  tube  ;  5,  cardiac  pouch  largely  dilated  ;  6,  lesser 
curvature  pulled  down  toward  the  greater. 

be  more  frequent.    Thus,  Fenwick  in  his  work  writes  :  "  In  about 
45  per  cent,  of  the  cases  which  have  been  recorded  neither  ulcer 


PATHOGENY.  35 

nor  scar  could  be  detected  in  the  stomach,  while  in  the  great 
majority  of  cases  where  an  ulcer  was  present  it  was  obviously  of 
more  recent  formation  than  the  stricture ; "  and,  again,  "  that  the 
deformity  is  a  rare  result  of  ulceration  is  proved  by  the  fact  that 
only  one  case  of  the  kind  is  mentioned  in  the  records  of  the  Lon- 
don Hospital  for  forty  years,  whereas  several  instances  of  the  con- 
genital form  of  the  disease  were  encountered  during  the  same 
period  of  time." 

Meckel  considered  that  a  congenital  hour-glass  stomach  might 
result  from  an  imperfection  of  development,  and  Cruveilhier  and 
others  have  suggested  that  the  sacculation  is  an  instance  of  atav- 
ism, and  that  there  is  an  analogy  between  such  a  deformity  and 
the  normal  bifid  stomach  of  certain  rodents  and  the  pouched 
stomachs  of  ruminants. 

On  examination  of  specimens  of  hour-glass  stomach  there  can 
occasionally  be  seen  two  crossing  bundles  of  muscular  fibers  on 
each  surface  of  the  organ.  These  were  first  noticed  by  Mari- 
otti,  but  were  more  fully  described  by  Saake.  The  bundles  are 
generally  half  an  inch  or  more  in  width,  and  cross  at  the  point  of 
narrowing  in  the  stomach.  Traced  from  the  upper  side  of  the  car- 
diac complement,  a  bundle  is  seen  to  pass  to  the  lower  side  of  the 
pyloric,  and  from  the  lower  side  of  the  cardiac  complement  to  the 
upper  part  of  the  pyloric,  the  fibers  crossing  like  the  widely 
opened  blades  of  a  pair  of  scissors.  It  has  been  suggested  that 
these  outstanding  bands  of  muscle  by  their  contraction  deter- 
mine the  hour-glass  form  of  the  stomach,  and  their  existence 
is  held  to  be  proof  of  the  "  congenital  "  origin  of  the  deformity. 
In  the  only  example  I  have  seen  of  this  muscular  arrangement  the 
hour-glass  stomach  was  clearly  the  result  of  an  ulcer,  whose  edges 
were  immensely  thickened  and  whose  base  had  perforated.  In  this 
case  the  bundles  of  fibers  followed  the  lines  of  puckering  pro- 
duced by  the  contraction  of  the  ulcer,  and  were  therefore  clearly 
the  result,  and  not  the  cause,  of  the  deformity. 

Cumston  and  other  writers  have  said  that  in  congenital  hour- 
glass stomach  the  two  pouches  are  connected  by  a  tube  or  cylinder 
showing  no  scar  of  ulceration,  and  free  externally  from  all  adhe- 
sions. One  such  case  I  have  dealt  with  by  operation.  I  slit  up 
the  channel  connecting  the  two  sacs,  and  found  a  perfect  example 


36  HOUE-GLASS   STOMACH. 

of  "bridle"  stricture,  the  result  of  healing  in  an  ulcer  which  from 
the  mucous  surface  was  easily  seen  and  felt. 

An  example  of  congenital  hour-glass  stomach  is  said  to  have 
been  recorded  by  Sandifort ;  the  specimen  was  obtained  from  a 
fetus.  But  the  appearance  of  hour-glass  deformity  may  be 
mimicked  with  remarkable  accuracy  by  a  condition  of  dilatation 
of  the  stomach  and  of  the  upper  part  of  the  duodenum,  as  the 
result  of  a  congenital  narrowing  of  the  duodenum  at  or  near  the 
bile  papilla.  Such  a  case  is  recorded  by  Wyss.  Sandifort's  case 
is  certainly  open  to  question,  for  the  description  is  not  convincing. 

In  all  the  recorded  examples  of  hour-glass  stomach  where  a  full 
examination  of  the  viscus  had  been  made,  ulceration  has  been 
found.  For  those  who  believe  that  the  deformity  is  congenital  the 
theory  that  the  ulcer  is  secondary  is  sufficient.  Thus,  Cumston 
writes  :  "  These  ulcers  are  secondary,  and  are  probably  produced 
by  the  pressure  of  the  food  passing  through  the  strictured  part  of 
the  organ." 

Roger  Williams,  in  1883,  described  ten  examples  of  "congeni- 
tal" contraction  of  the  stomach.  The  account  of  one  of  the 
cases  is  based  on  the  examination  of  a  wax  model  ;  of  another,  on 
the  inspection  of  an  "  inflated  dried  "  specimen  ;  and  of  a  third, 
on  the  appearance  of  a  dried  stuffed  specimen.  It  is  doubtful 
whether  one  of  the  examples  can  be  accepted  as  an  hour-glass 
stomach.  In  all  the  others  pathologic  conditions — ulceration, 
puckering,  thickening,  or  adhesions — were  found. 

Hochenegg,  Carrington,  Maier,  Saake,  and  many  other  writers 
who  describe  their  examples  as  "  congenital "  mention  thickening, 
old  ulceration,  adhesion  to  the  pancreas  or  to  the  abdominal  wall, 
localized  perforation,  and  other  conditions  which  are  indubitably 
the  result  of  chronic  ulcer  of  the  stomach.  Doyen,  in  his  work 
on  the  diseases  of  the  stomach  and  duodenum,  refers  to  a  case  in 
which,  at  the  isthmus  of  the  stomach,  an  adhesion  to  the  anterior 
abdominal  wall  was  found  ;  on  breaking  through  this,  a  gastric 
fistula  was  exposed,  showing  unmistakably  that  an  ulcer  had  been 
present,  which  had  been  prevented  from  perforating  into  the  peri- 
toneal cavity  only  by  the  anchoring  of  the  organ  to  the  anterior 
abdominal  wall.     This  is  said  to  be  "  congenital," 

Mazotti  relates  a  case  of  "  congenital  "  hour-glass  stomach  in 


ETIOLOGY.  ■  37 

a  woman  of  fifty  ;  he  believes  the  deformity  to  l)e  due  to  an 
unusual  development  of  the  transverse  muscular  fibers  in  a  certain 
part  of  the  wall  of  the  viscus.  Without  entering  in  detail  into 
this  discussion,  I  may  say  that  I  have  very  carefully  considered 
the  question  as  to  the  existence  of  hour-glass  stomach  as  a  con- 
genital deformity,  examining  all  the  specimens  that  I  could  find, 
and  reading  carefully  the  records  of,  I  believe,  all  the  published 
cases ;  but  I  remain  confident  in  my  belief  that  tliere  is  no  evi- 
dence whatever  which  will  establish  the  claim  of  those  who  assert 
that  the  disease  is  often  congenital  in  origin.  Since  I  first  threw 
doubts  upon  the  congenital  origin  of  many  of  the  cases  of  hour- 
glass stomach,  and  showed  that  in  almost  all  of  the  cases  obvious 
evidence  of  old  ulceration  could  be  found,  several  investigators 
have  supported  my  conclusion  by  observations  made  during  the 
course  of  operation  or  on  post-mortem  examination.  There  is,  in- 
deed, no  inherent  improbability  in  the  existence  of  congenital 
hour-glass  stomach,  but  it  lacks  proof. 

Acquired  hour-glass  stomach  may  be  caused  by  :  (1)  Perigas- 
tric adhesions  ;  (2)  ulcer,  with  local  perforation  and  anchoring  to 
the  anterior  abdominal  wall ;  (3)  chronic  ulcer,  generally  at  or 
near  the  middle  of  the  organ  ;  (4)  malignant  disease. 

1.  Perigast7'ic  adhesions  may  result  from  many  causes — gastric 
ulcer,  old  tuberculous  peritonitis,  inflammatory  affections  of  the 
gall-bladder,  and  so  forth.  In  rare  instances  these  adhesions  may 
be  the  sole  cause  of  the  partition  of  the  stomach ;  in  many  in- 
stances they  are  no  more  than  contributing  causes.  They  were 
well  seen  in  a  case  related  by  Cumston. 

2.  Ulcer  U'ith  local  perforation  and  anchoring  of  the  stomach  to 
the  anterior  abdomincd  wall.  This  was  the  condition  I  found  in  my 
first  case.  It  results  from  gradual  deepening  of  a  chronic  ulcer. 
As  the  ulcer  approaches  the  serous  coat  of  the  stomach,  a  few  ad- 
hesions form,  binding  the  viscus  to  the  anterior  abdominal  wall, 
preventing  the  bursting  of  the  ulcer  into  the  general  peritoneal 
cavity.  If  the  ulcer  be  on  the  posterior  surface,  a  soldering  to 
the  pancreas  may  result,  as  in  one  case  I  have  recently  seen. 
When  the  stomach  is  anchored  in  its  middle,  the  pouches  on  each 
side,  but  more  especially  on  the  cardiac  side,  show  a  tendency  to 
sagging,  and  this,  with  the  cicatricial  contraction  taking  place  in 


38 


HOUE-GLASS    STOMACH. 


the  ulcer,  results  in  hour-glass  form  of  the  stomach.  In  one 
of  my  cases  a  malignant  mass  in  the  anterior  wall  had  formed  an 
extensive  adhesion  to  the  bodj-wall.  Doyen,  Steffan,  and  Finney 
have  recorded  similar  examples. 

In  three  recorded  cases  an  ulcer  at  the  isthmus  of  an  hour-glass 
stomach  has  perforated  into  the  peritoneum  and  caused  death. 
The  first  case  was  related  by  Siewers,  the  second  by  my  friend 
Mr.  W.  H.  Brown,  and  the  third  by  Thomsen  (Hospitals  tidende 
1901,  N.  23,  Kopenhagen). 

3.    Chronic  ulcer.  A  chronic  ulcer  of  the  stomach  is  character- 


Fig.  9. — Hour-glass  stomach  showing  perforation  (W.  H.  Brown's  case). 

ized  by  the  thickening  and  induration  at  its  base.  In  the  heal- 
ing of  such  an  ulcer,  especially  if  large  in  size  or  circular,  a  con- 
siderable amount  of  contraction  will  necessarily  take  place,  and  a 
high  degree  of  narrowing  of  the  stomach  may  result.  There  is, 
I  believe,  in  addition  to  the  cicatricial  contraction,  another  factor  of 
chief  importance  in  determining  the  narrowing  of  the  organ.  I 
refer  to  spasm.  On  several  occasions  during  the  last  two  years, 
when  operating  for  chronic  ulcer,  I  have  watched  the  stomach  in- 
tently for  several  minutes,  and  have  seen  the  onset,  the  acme,  and 
the  gradual  relaxation  of  a  spasmodic  muscular  contraction  in  its 


ETIOLOGY.  39 

walls.  Quite  gradually  the  stomach  narrows,  and  the  wall  be- 
comes thicker  and  almost  white  in  color  ;  when  taken  between  the 
fingers  the  contracted  area  feels  like  a  solid  tumor.  The  spasm 
may  be  so  marked  as  to  prevent  a  finger  being  invaginated  through 
the  segment  affected.  The  appearance  presented  is  very  striking. 
I  have  seen  it  in  the  body  of  the  stomach  and  at  the  pylorus.  As 
slowly  as  it  comes  on,  the  spasm  quietly  relaxes,  and  the  stomach 
assumes  its  usual  form.  In  one  patient  I  watched  four  such  spas- 
modic seizures  at  the  pylorus  in  a  few  minutes,  and  the  tumor 
formed  by  the  tightly  contracted  muscle  was  so  large  that  in  a  very 
thiu  subject  it  should  have  been  felt  on  palpation  of  the  abdomen. 
Such  constantly  recurring  attacks  of  spasm  must  lead  to  an  hyper- 
trophy of  the  circular  muscular  fibers,  and  this  thickening,  to- 
gether with  the  cicatricial  contraction  and  the  induration  of  the 
ulcer,  will  amply  account  for  the  extreme  narrowing  of  the  stomach 
cavity,  with  the  dense  thickening  of  the  walls  met  with  in  many 
of  the  examples  recorded. 

The  extent  to  which  spasmodic  contraction,  invoked  by  ulcer- 
ation, is  responsible  for  the  narrowing  found  in  hour-glass  stomach 
(and  congenital  stenosis)  is  not  capable  of  being  measured ;  but 
my  observation  of  the  cases  I  have  seen  during  the  last  two  years 
makes  me  ready  to  believe  that  it  is  not  inconsiderable. 

Klein  has  recorded  one  example  of  hour-glass  stomach  result- 
ing from  the  contraction  of  an  ulcer  which  had  been  caused  by  the 
drinking  of  hydrochloric  acid  with  suicidal  intent.  Syphilis  of 
the  stomach  may  result  in  nicer  or  gumma  and  in  consecutive 
warping  of  the  viscus. 

The  amount  of  induration  found  around  a  chronic  ulcer  may  be 
so  considerable,  and  its  density  so  marked,  that  a  mistaken  diag- 
nosis of  malignant  disease  of  the  stomach  may  be  made.  This 
happened  in  Case  11  of  my  list.  A  large,  densely  hard,  immovable 
mass,  adherent  to  the  pancreas,  was  found  in  the  stomach  walls 
between  the  two  loculi.  The  appearance  of  malignant  disease  was 
accurately  simulated.  I  could  not  remove  the  mass,  and  could 
not  reach  the  cardiac  pouch  with  sufficient  ease  to  allow  me  to 
perform  a  gastro-enterostomy,  and  I  was  therefore  only  able  to 
dilate  the  constriction  between  the  two  pouches.  After  consider- 
able pressure  I  succeeded  in  invaginating  my  little  finger  through 


40  HOUR-GLASS    STOMACH. 

the  isthmus,  and  slowly  dilated  it  until  three  fingers  would  pass 
through.  I  hoped  by  so  doing  to  lessen  the  distress  of  vomiting, 
which  had  been  almost  continuous.  The  patient  speedily  recov- 
ered, and  now,  after  two  years,  is  perfectly  well ;  she  has  gained 
2 1  stones  in  weight,  is  ruddy  and  healthy  in  appearance,  and  the 
tumor,  readily  palpable  before  the  operation,  has  entirely  disap- 
peared. 

One  point  which  is,  I  believe,  deserving  of  especial  emphasis 
is  the  frequency  with  which,  in  cases  of  hour-glass  stomach  due  to 
chronic  ulcer,  a  narrowing  of  the  pylorus  is  also  found.  The  con- 
striction in  the  middle  of  the  stomach  hinders  the  passage  of  food 
from  {he  cardiac  to  the  pyloric  pouch;  the  narrowing  at  the 
pylorus  makes  difficult  the  emptying  of  the  pyloric  sac,  which,  in 
consequence,  undergoes  dilatation.  This  double  constriction  is  an 
illustration  of  the  fact  I  have  verified  in  operations  upon  the 
stomach — the  frequency  of  multiple  ulcers  in  the  stomach,  or  in 
the  duodenum,  or  in  both.  If  the  cardiac  loculus  alone  is 
obstructed,  the  pylorus  being  free,  the  walls  of  the  former  are 
much  thicker  than  those  of  the  latter.  Lunnemann,  in  such  a 
case,  found  the  circular  muscular  fibers  2  to  2.5  mm.  thick  on  the 
cardiac  side,  and  only  1  to  1.5  mm.  on  the  pyloric.  It  is  possible 
that  the  contraction  found  at  the  pylorus  may  be  the  result  of  a 
long-continued  spasm,  set  up  by  the  ulcer  whose  healing  has  caused 
the  hour-glass  shape  of  the  stomach.  Frequent  spasm  would  cause 
hypertrophy  of  the  muscular  coats,  and  fibrous  transformation 
would  occur  in  the  over-developed  muscle.  In  one  case  under  my 
care  a  double  constriction  had  been  formed  in  the  stomach  and 
three  pouches  had  thereby  resulted.  This  is  the  only  recorded 
example  of  trifid  stomach  due  to  ulceration. 

Jf..  Cancer.  Cancer  as  a  cause  of  hoar-glass  stomach  is  not 
infrequent.  Three  specimens  of  this  kind  are  in  the  Museum  .of 
the  Royal  College  of  Surgeons  in  London.  I  have  operated  upon 
two  cases.  In  the  first  the  malignant  disease,  beginning  rather 
nearer  the  cardiac  than  the  pyloric  end  of  the  stomach,  had  infil- 
trated the  greater  part  of  the  organ,  and  had  resulted  in  a  condition 
of  "  leather  bottle  "  stomach.  In  the  second  a  large  chronic  ulcer, 
with  carcinoma  implanted  upon  it — "  ulcus  carcinomatosum  " — 
was  found. 


SYMPTOMS.  41 

SYMPTOMS  OF  HOUR-GLASS  STOMACH. 

An  hour-glass  stomach  can  be  diagnosed  with  certainty  if 
attention  be  paid  to  a  certain  comlaination  of  symptoms.  In  my 
first  six  cases  only  one  was  diagnosed  ;,  in  my  last  eight  cases  six 
were  diagnosed  with  certainty ;  in  one  of  these  the  diagnosis 
was  made  by  the  medical  attendant,  Dr.  M'Gregor  Young,  before 
I  was  asked  by  him  to  see  the  patient.  The  symptoms  will  natu- 
rally vary  according  to  the  position  of  the  constriction  in  the 
stomach  :  if  this  lies  near  the  cardiac  orifice,  the  clinical  picture 
will  resemble  that  given  by  esophageal  obstruction  low  down ;  if 
near  the  pyloric  orifice,  the  symptoms  are  those  of  dilated  stomach. 
But  w^herever  the  narrowing  may  be,  attention  to  the  following 
signs  will,  in  almost  every  case,  enable  a  diagnosis  to  be  made  with 
confidence : 

1.  If  the  stomach  tube  be  passed,  and  the  stomach  washed  out 
with  a  known  quantity  of  fluid,  the  loss  of  a  certain  quantity  will 
be  observed  when  the  return  fluid  is  measured.  Thus,  if  30  ounces 
be  used,  only  24  can  be  made  to  return,  as  in  Dr.  M'Gregor 
Young's  case  already  mentioned.  Wolfler,  who  called  attention 
to  this  sign,  said  that  some  fluid  seemed  to  disappear  "  as  though 
it  had  flowed  through  a  large  hole  " — as  indeed  it  has,  in  passing 
from  the  cardiac  to  the  pyloric  pouch  (Wolfler's  "  first  sign  "). 

2.  If  the  stomach  be  washed  out  until  the  fluid  returns  clear, 
a  sudden  rush  of  foul,  evil-smelling  fluid  may  occur ;  or  if  the 
stomach  be  washed  clean,  the  tube  withdrawn  and  passed  again,  in 
a  few  minutes  several  ounces  of  dirty,  offensive  fluid  may  escape. 
The  fluid  has  regurgitated  through  the  connecting  channel  between 
the  pyloric  and  cardiac  pouches  (Wolfler's  "  second  sign  "). 

3.  Paradoxical  dilatation.  If  the  stomach  be  palpated  and 
a  succussion  splash  obtained,  the  stomach-tube  passed,  and  the 
stomach  apparently  emptied,  palpation  will  still  elicit  a  distinct 
splashing  sound.  This  is  due  to  the  fact  that  only  the  cardiac 
pouch  is  drained  ;  the  contents  of  the  pyloric  remain  undisturbed, 
and  cause  the  splashing  sound  on  palpation.  For  this  phenomenon 
Jaworski  has  suggested  the  appropriate  name  of  "  paradoxical  dila- 
tation." Jaboulay  has  pointed  out  that  if  the  cardiac  loculus  be 
filled  with  water,  a  splashing  sound  can  still  be  obtained  by  palpa- 


42  HOUE-GLASS    STOMACH. 

tion  over  the  pyloric  pouch.  The  sign  of  paradoxical  dilatation  is 
best  elicited  after  washing  out  the  stomach  in  the  ordinary  manner. 
When  the  abdomen  is  examined  at  the  completion  of  the  washing, 
and  when  the  stomach  has  been  apparently  drained  quite  dry,  a 
splashing  sound  is  readily  obtained,  for  some  of  the  fluid  used  has 
escaped  into  the  pyloric  pouch  through  the  connecting  channel. 

4.  Von  Eiselsberg  observed  in  one  of  his  cases  that  on  dis- 
tending the  stomach  a  bulging  of  the  left  side  of  the  epigastrium 
was  produced ;  after  a  few  moments  this  gradually  subsided,  and 
concomitantly  there  was  a  gradual  filling  up  and  bulging  of  the 
right  side. 

5.  Von  Eiselsberg  also  called  attention  to  the  bubbling,  forcing, 
"  sizzling "  sound  which  can  be  heard  when  the  stethoscope  is 
applied  over  the  stomach,  after  distention  with  CO^.  If  the  two 
halves  of  a  seidlitz  powder  are  separately  given,  and  the  stomach 
be  normal  or  dilated,  no  loud  sound  is  heard  anywhere  except  at 
the  pylorus  ;  if  a  constriction  is  present  in  the  stomach,  a  loud, 
forcible,  gushing  sound  can  be  easily  distinguished,  at  a  point  2  or 
3  inches  to  the  left  of  the  middle  line. 

6.  I  first  called  attention,  two  years  ago,  to  a  sign  which  I 
have  since  found  of  great  service  in  establishing  a  diagnosis  of 
hour-glass  stomach.  The  abdomen  is  carefully  examined  and  the 
stomach  resonance  is  percussed.  A  seidlitz  powder  in  two  halves 
is  then  administered.  On  percussing,  after  about  twenty  or  thirty 
seconds,  an  enormous  increase  in  the  resonance  of  the  upper  part 
of  the  stomach  can  be  found,  while  the  lower  part  remains  unaltered. 
If  the  pyloric  pouch  can  be  felt,  or  seen  to  be  clearly  demarcated, 
the  diagnosis  is  inevitable,  for  the  increase  in  resonance  must  be  in 
a  distended  cardiac  segment.  If  the  abdomen  be  watched  for  a 
few  minutes,  the  pyloric  pouch  may  sometimes  be  seen  gradually 
to  fill  and  become  prominent. 

7.  Schmidt-Monard  and  Eichhorst  have  both  seen  a  distinct 
sulcus  between  the  two  pouches  inflated  with  CO^.  In  Case  10  in 
my  list,  the  two  pouches,  with  a  hard,  as  I  thought,  malignant, 
mass  between  them,  could  readily  be  seen.  When  both  pouches 
were  distended  with  CO^,  alternate  pressure  upon  them  showed 
unmistakably  that  they  communicated  through  a  very  narrow 
orifice,  for  the  one  could  be  emptied  slowly  into  the  other,  and  the 


DIFFERENTIAL    DIAGNOSIS.  43 

fluid  could  be  felt  to  ripple  gently  through.  The  diagnosis  in  such  a 
case  is  simplicity  itself.  In  Case  8  a  distinct  notch  was  seen  at 
the  lower  border  of  the  inflated  stomach. 

8.  Ewald  has  called  attention  to  two  signs  which  he  considers  of 
value  in  establishing  a  diagnosis.  When  the  stomach  is  filled  with 
water  and  examined  by  gastro-diaphany,  the  transillumination  is 
seen  only  in  the  cardiac  pouch  ;  the   pyloric  pouch  remains  dark. 

9.  The  deglutable  india-rubber  bag  of  Turck  and  Hemmeter 
is  passed  and  distended.  The  bulging  caused  thereby  is  limited 
to  the  cardiac  pouch,  which  lies  to  the  left  of  the  middle  line. 

The  two  aids  to  diagnosis  of  greatest  value  are,  it  will  be 
seen,  the  washing  out  of  the  stomach,  and  its  inflation  with  gas  by 
the  administration  of  a  seidlitz  powder  in  two  portions.  The  fluid 
used  for  the  washing  must  be  carefully  measured  before  use  ;  the 
tube  is  then  passed,  and  the  stomach  emptied,  the  contents  set 
aside  in  a  separate  dish,  and  the  washing  commenced.  All  the 
fluid  now  returning  is  collected  in  a  separate  vessel  and  carefully 
measured.  The  two  signs  of  Ewald  are  of  little  importance ;  a 
correct  diagnosis  can  always  be  made  without'them. 


DIFFERENTIAL  DIAGNOSIS. 

The  two  conditions  for  which  an  hour-glass  stomach  is  liable 
to  be  mistaken  are  obstruction  in  the  lower  part  of  the  esoph- 
agus and  pyloric  stenosis.  If  the  constriction  in  the  stomach  is 
within  an  inch  or  two  of  the  cardiac  orifice,  the  upper  loculus  of  the 
stomach  will  be  very  small  in  size,  and  capable,  therefore,  of  hold- 
ing only  small  quantities  of  food.  Food,  when  swallowed,  may 
be  regurgitated  within  a  few  minutes  almost  unaltered,  and  the 
patient  may  tell  the  same  story  of  difficulty  in  "  getting  the  food 
down  "  as  is  told  by  one  whose  esophagus  is  obstructed,  A  correct 
diagnosis  can  be  made  by  introducing  the  esophageal  bougie  ;  if 
the  bougie  passes  over  16  inches  from  the  teeth,  the  obstruction 
does  not  lie  in  the  stomach. 

If  the  constriction  be  near  the  pylorus,  the  cardiac  comple- 
ment will  be  dilated,  and  will  present  the  same  appearance  and 
signs  as  a  dilated  stomach.  Wolfler's  two  signs  (1  and  2  in  the 
list  given)  will  generally  enable  a  correct  diagnosis  to  be  achieved. 


44  HOUR-GLASS   STOMACH. 

If  the  obstruction  should  lie  at  any  point  between  the  two 
mentioned,  there  should  be  no  difficulty  in  making  a  correct  diag- 
nosis. 

TREATMENT. 

The  treatment  of  hour-glass  stomach  may  be  beset  with  dif- 
ficulties. If  the  stricture  is  near  the  cardiac,  or  if  the  cardiac 
complement  be  bound  up  in  adhesions,  there  may  be  great  me- 
chanical hindrance  to  the  performance  of  any  operation.  When 
the  abdomen  is  opened,  a  thorough  examination  of  the  whole 
stomach  must  first  be  made.  The  dilated  pyloric  sac  may  so  com- 
pletely resemble  the  whole  stomach  as  to  lead  to  the  performance 
of  a  gastro-enterostomy  between  it  and  a  loop  of  the  jejunum. 
Several  cases  are  recorded  in  which  this  mistake  has  been  made, 
and  it  is  therefore  necessary  to  emphasize  the  importance  of  an 
examination  of  the  whole  stomach  up  to  the  cardiac  orifice  in  every 
case,  no  matter  how  obvious  the  diagnosis  of  "  dilated  stomach  " 
may  have  seemed.  ^ 

In  one  case,  that  in  which  a  "  trifid  "  stomach  was  found,  I 
had  diagnosed  hour-glass  stomach  after  eliciting  several  of  the 
signs  mentioned.  On  opening  the  abdomen  I  exposed  at  once  a 
perfect  example  of  bilocular  stomach ;  the  two  pouches  and  the 
intervening  constriction  were  well  seen.  After  completing  my 
demonstration  of  this  I  remarked  to  my  assistant  that  I  never 
began  a  stomach  anastomosis  until  I  had  seen  all  the  viscus,  quite 
up  to  the  cardiac  end.  On  continuing  my  examination  in  this  direc- 
tion I  exposed  a  second  constriction  and  a  pouch.  There  were 
then  three  pouches  and  two  constrictions. 

In  many  cases  of  hour-glass  stomach  no  single  operation  will 
suffice  to  relieve  the  symptoms.  This  is  due  to  the  fact,  already 
mentioned,  that  where  a  stricture  is  present  in  the  body  of  the 
stomach,  a  second  stricture  near  the  pylorus  may  also  be  found. 
If  there  be  any  dilatation  of  the  pyloric  complement,  a  constriction 
at  the  pylorus  or  in  the  duodenum  will  certainly  be  found.  This 
dual  stenosis,  which  has  not  received  adequate  attention  from  any 
writer,  accounts  for  the  lack  of  permanent  improvement  seen  in 
many  of  the  recorded  cases.  If  in  such  circumstances  a  gastro- 
enterostomy   is    performed   between    the   cardiac    pouch  and  the 


OPERATIONS.  45 

jejunum,  the  pyloric  pouch  becomes  a  reservoir  incapable  of  effi- 
cient emptying,  wherein  food  lodges  and  becomes  sour.  Symptoms 
of  stasis  are  then  observed — acid,  bitter  eructations,  occasional 
vomiting,  a  sense  of  heaviness  and  heat  at  the  epigastrium,  and 
distaste  for  food — and,  as  in  a  case  recorded  by  Terrier,  a  second 
operation  is  necessary.  If  a  gastroplasty  is  performed,  the  stom- 
ach cannot  empty  itself  because  of  the  p}^oric  stenosis,  and  the 
symptoms  are  unrelieved.  Such  a  condition  of  double  stenosis 
can  therefore  be  adequately  treated  only  by  the  performance  of 
two  operations  at  the  same  time — gastroplasty  and  pyloroplasty  ; 
gastroplasty  and  gastro-enterostomy  from  the  pyloric  pouch  ;  gastro- 
gastrostomy  and  gastro-enterostomy  ;  or  a  double  gastro-enteros- 
tomy, a  loop  of  jejunum  being  opened  at  two  points,  at  the  upper 
into  the  cardiac  pouch,  at  the  lower  into  the  pyloric. 

In  operating  upon  hour-glass  stomachs  I  have  noticed  on  sev- 
eral occasions  that  the  pyloric  pouch  was  partially  filled  with  a 
dirty-looking  and  slightly  oifensive  fluid.  In  washing  out  the 
stomach  before  operation,  it  is  obvious  that  when  the  stricture  is 
narrow  the  cardiac  pouch  only  is  cleansed.  In  the  pyloric  pouch 
food  remains  stagnant  for  lengthy  periods  and  may  become  foul, 
■putrid,  evil-smelling.  Before  opening  the  pyloric  sac  for  the 
purposes  of  anastomosis,  it  may  be  necessary  to  empty  it  of  its 
contents  through  a  needle  to  which  is  attached  a  long  tube.  Leak- 
age from  the  pouch  should  be  prevented,  and  any  swabs  used  to 
dry  the  surface  when  cut  should  be  instantly  discarded. 

The  following  are  the  operations  that  may  be  practised  : 

1.  Gastroplasty. 

2.  Gastro-gastrostomy  or  gastro-anastomosis. 

3.  Either  of  the  foregoing,  with  gastro-enterostomy  from  the 
pyloric  pouch,  in  cases  of  dual  stenosis. 

4.  Gastro-enterostomy  from  the  cardiac  pouch,  when  the  py- 
loric pouch  is  so  small  that  it  can  be  ignored. 

5.  Gastro-enterostomy  from  both  pouches. 

6.  Partial  gastrectomy. 

The  operation  selected  will  necessarily  depend  upon  the  con- 
dition which  is  found.     Thus  I  performed  : — 
Gastroplasty  alone  in  Cases  1,  2,  3,  5,  11. 
Gastro-enterostomy  alone  in  Cases  6,  7,  8,  9. 


46 


HOUR-GLASS    STOMACH. 


Gastroplasty  and  gastro-enterostomy  in  Cases  12,  13. 
Gastro-gastrostomy  alone  in  Case  4. 

Gastro-gastrostomy  and  gastro-enterostomy  in  Cases  14,  15. 
Partial   gastrectomy  is  the  operation   of  choice  in   cases  of 
malignant  stricture  in  the  body  of  the  stomach. 


Fig.  10. — Diagrams  showing  the  operatious  for  hour-glass  stomach  :  1,  Gastro- 
gastrostomy  ;  2,  3,  gastroplasty  ;  4,  double  gastro-enterostomy  ;  5,  partial 
gastrectomy  ;  6,  gastro-enterostomy  from  the  cardiac  pouch. 

Gastroplasty  was  first  performed  by  Bardeleben  in  1889,  later 
by  Kruckenberg,  Doyen,  and  others. 

Gastro-gastrostomy  was  first  performed  by  Wolfler  in  1894. 
In  1895  Sedgwick  Watson  performed  a  gastro-anastomosis  by 
folding  the  pyloric  pouch  over  the  cardiac  pouch,  with  the  con- 
striction as  a  hinge,  and  uniting  the  apposed  surfaces. 


TABLES  OF  CASES. 


Table  I. 

Perforating  Ulcer. 

12  cases. 

6  recoveries, 

Table  II. 

Gastro-enterostomy. 

69  cases. 

1  death. 

Table  III. 

Pyloroplasty. 

3  cases. 

0  death. 

Table  IY. 

Hour-glass  Stomach. 

15  cases. 

3  deaths. 

Excision  of 

Ulcee. 

1  case. 

Death. 

Gasteoplication. 

1  case. 

Recovery. 

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83 


SAUNDERS'    BOOKS 

on 

SURGERY 

and 

ANATOMY 


W.  B.  SAVNDERS   ®.    COMPANY 

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SAUNDERS'  BOOKS  ON 


American 
Text-Book  of  Surgery 

American  Text=Book  of  Surgery.  Edited  by  William  W.  Keen, 
M.D.,  LL.D.,  F.R.C.S.  (Hon.),  Professor  of  the  Principles  of  Sur- 
gery and  of  Clinical  Surgery,  Jefferson  Medical  College,  Philadel- 
phia;  and  J.  William  White,  M.D.,  Ph.D.,  John  Rhea  Barton 
Professor  of  Surgery,  University  of  Pennsylvania.  Handsome  octavo, 
1230  pages,  with  496  wood-cuts  in  the  text  and  37  colored  and  half- 
tone plates.         Cloth,  ^7.00  net ;  Sheep  or  Half  Morocco,  ^8.00  net. 

THIRD  EDITION,  THOROVGHLY  REVISED  AND  ENLARGED 

Of  the  two  former  editions  of  this  book  there  have  been  sold  over  36,000 
copies.  This  and  its  adoption  as  a  text-book  in  eighty-five  medical  colleges 
have  furnished  a  stimulus  to  the  authors  to  keep  the  work  abreast  of  the  times 
by  another  careful  revision.  This  has  been  accomplished  by  a  vigorous  scrutiny 
of  all  the  old  matter,  by  the  enlargement  of  several  sections,  by  the  addition  of 
new  illustrations,  and  by  the  introduction  of  the  many  new  topics  that  have  come 
to  the  front  in  the  surgery  of  to-day.  Among  the  new  topics  introduced  are 
a  full  consideration  of  serum-therapy  ;  leucocytosis  ;  post-operative  insanity ; 
Kronlein's  method  of  locating  the  cerebral  fissures  ;  Hoffa's  and  Lorenz's  oper- 
ations of  congenital  dislocations  of  the  hip  ;  Allis'  researches  on  dislocations  of 
the  hip-joint ;  lumbar  puncture  ;  the  forcible  reposition  of  the  spine  in  Pott's  dis- 
ease ;  the  use  of  Kelly' s  rectal  specula  ;  the  use  of  eucain  for  local  anesthesia ; 
Krause's  method  of  skin-grafting,  etc. 


PERSONAL  AND  PRESS  OPINIONS 

Edmond  Owen,  F.R.C.S.. 

Member  of  the  Board  of  Examiners  of  the  Royal  College  of  Siirgeons,  England. 
"  Personally,  I  should  not  mind  it  being  called  The  Text-Book  (instead  of  A  Text-Book),  for  I 
know  of  no  single  volume  which  contains  so  readable  and  complete  an  account  of  the  science  and  art 
of  surgery  as  this  does." 

The  La.i\cet,  London 

"  If  this  text-book  is  a  fair  reflex  of  the  present  position  of  American  surgery,  we  must  admit  it 
is  of  a  very  high  order  of  merit,  and  that  English  surgeons  will  have  to  look  very  carefully  to  their 
laurels  if  they  are  to  preserve  a  position  in  the  van  of  surgical  practice." 

Boston  Medica.1  3Lnd  Surgical  Jourival 

"  This  book  marks  an  epoch  in  American  book-making.  All  in  all,  the  book  is  distinctly  the 
most  satisfactory  work  on  modern  surgery  with  which  we  are  familiar.  It  is  thorough,  complete,  and 
condensed." 


SURGERY  AND  ANATOMY 


Irvterrvatiorval 
Text-Book  of  Surgery 

SECOND  EDITION,  THOR.OVGHLY  REVISED  AND  ENLARGED 

The  International  Text=Book  of  Surgery.  In  two  volumes.  By 
American  and  British  authors.  Edited  by  J.  Collins  Warren,  M.D., 
LL.D.,  F.R.C.S.  (Hon.),  Professor  of  Surgery,  Harvard  Medical 
School;  and  A.  Pearce  Gould,  M.S.,  F.R.C.S.,  of  London,  England. — 
Vol.  I.  General  and  Operative  Snrgery.  Royal  octavo,  975  pages, 
461  illustrations,  9  full-page  colored  plates. — Vol.  II.  Special  or 
Regional  Surgery.  Royal  octavo,  1122  pages,  499  illustrations,  and 
8  full-page  colored  plates. 

Per  volume  :   Cloth,  ^5.00  net;   Half  Morocco,  $6.00  net. 

ADOPTED  BY  THE  U.  S.  AR_MY 

In  this  new  edition  the  entire  book  has  been  carefully  revised,  and  special  effort 
has  been  made  to  bring  the  work  down  to  the  present  day.  The  chapters  on 
Military  and  Naval  Surgery  have  been  very  carefully  revised  and  extensively 
rewritten  in  the  light  of  the  knowledge  gained  during  the  recent  wars.  The 
articles  on  the  effect  upon  the  human  body  of  the  various  kinds  of  bullets,  and 
the  results  of  surgery  in  the  field  are  based  on  the  latest  reports  of  the  sur- 
geons in  the  field.  The  chapter  on  Diseases  of  the  Lymphatic  System  has  been 
completely  rewritten  and  brought  up  to  date  ;  and  of  special  interest  is  the 
chapter  on  the  Spleen.  The  already  numerous  and  beautiful  illustrations  have 
been  greatly  increased,  constituting  a  valuable  feature,  especially  so  the  seven- 
teen colored  lithographic  plates. 


OPINIONS  OF  THE  MEDICAL  PRESS 

Anna.ls  of  Surgery 

"  It  is  the  most  valuable  work  on  the  subject  that  has  appeared  in  some  years.  The  clinician  and 
the  pathologist  have  joined  hands  in  its  production,  and  the  result  must  be  a  satisfaction  to  the  editors 
as  it  is  a  gratification  to  the  conscientious  reader." 

Boston  NedicaLl  aLnd  Surgica.1  JournaLl 

"  The  articles  as  a  rule  present  the  essentials  of  the  subject  treated  in  a  clear,  concise  manner. 
They  are  sj'stematically  written.  The  illustrations  are  abundant,  well  chosen,  and  enhance  greatly 
the  value  of  the  work.     The  book  is  a  thoroughly  modern  one." 

The  Medica.1  Kecord,  New  York 

"The  arrangement  of  subjects  is  excellent,  and  their  treatment  by  the  different  authors  is 
equally  so.  .  .  .  The  work  is  up  to  date  in  a  very  remarkable  degree,  many  of  the  latest  operations  in 
the  different  regional  parts  of  the  body  being  given  in  full  details.  There  is  not  a  chapter  in  the  work 
from  which  the  reader  may  not  learn  something  new." 


SAUNDERS'  BOOKS  ON 


Senn's 
Practical  Surgery 

Practical  Surgery.  A  Work  for  the  General  Practitioner.  By 
Nicholas  Senn,  M.D.,  Ph.D.,  LL.D.,  Professor  of  Surgery  in  Rush 
Medical  College,  Chicago  ;  Professor  of  Surgery  in  the  Chicago  Poly- 
clinic ;  Attending  Surgeon  to  the  Presbyterian  Hospital,  etc.  Hand- 
some octavo  volume  of  1133  pages,  with  650  illustrations,  many  of 
them  in  colors.  Cloth,  ^6.00  net ;  Sheep  or  Half  Morocco,  ^7.00  net. 
Sold  by  Subscription. 

DR.  SENN'S  GR-EAT  WORK 
Based  on  His  Operative  Experience  for  25  Years 

This  work  represents  the  practical  operative  experience  of  the  author  for  the 
last  twenty-five  years.  The  book  deals  with  practical  subjects,  and  its  contents 
are  devoted  to  those  sections  of  surgery  that  are  of  special  interest  to  the  general 
practitioner.  Special  attention  is  paid  to  emergency  surgery.  Shock,  hemor- 
rhage, and  wound  treatment  are  fully  considered.  All  emergency  operations 
that  come  under  the  care  of  the  general  practitioner  are  described  in  detail  and 
fully  illustrated. 

The  section  on  Military  Surgery  is  based  on  the  author's  experience  as 
chief  of  the  operating  staff  in  the  field  during  the  Spanish-American  War,  and 
on  his  observations  during  the  Greco-Turkish  War.  Intestinal  Surgery  is  given 
a  prominent  place,  and  the  consideration  of  this  subject  is  the  result  of  the 
clinical  experience  of  the  author  as  surgeon  and  teacher  of  surgery  for  a  quarter 
of  a  century.     The  text  is  profusely  illustrated. 


OPINIONS  OF  THE  MEDICAL  PRESS 

AniveLls  of  Surgery 

"  It  is  of  value  not  only  as  presenting  comprehensively  the  most  advanced  teachings  of  modern 
surgery  in  the  subjects  which  it  takes  up,  but  also  as  a  record  of  the  matured  opinions  and  practice  of 
an  accomplished  and  experienced  surgeon." 

QusLrterly  Medical  Journal,  England 

"  We  cannot  speak  too  highly  of  this  valuable  contribution  to  the  literature  of  practical  surgery. 
.   .   .   The  present  work  more  than  sustains  the  high  reputation  of  its  author." 

Buffalo  Medical  Journal 

"  As  an  intelligent  exposition  of  the  science  of  surgery  as  practiced  to-day  it  is  deserving  of 
commendation,  and  it  will  be  particularly  welcomed  by  the  general  practitioner." 


SURCER  Y  AND  ANA  TO  MY 


Sc\idder's 
Treatment  of  Fractures 

The  Treatment  of  Fractures.  By  Charles  L.  Scudder,  M.D., 
Assistant  in  Clinical  and  Operative  Surgery,  Harvard  Medical  School; 
Surgeon  to  the  Out- Patient  Department  of  the  Massachusetts  General 
Hospital,  Boston.  Handsome  octavo  volume  of  485  pages,  with 
645  original  illustrations. 

Polished  Buckram,  ^4.50  net;  Half  Morocco,  $5.50  net. 

THE  THIRD  LARGE  EDITION  IN  TWO  YEARS 

In  this  edition  several  new  fractures  have  been  described,  and  an  excellent 
chapter  on  Gunshot  Fractures  of  the  long  bones  has  been  added.  The  reports 
of  surgeons  in  the  field  during  the  recent  wars  have  been  carefully  digested,  and 
the  important  facts  regarding  fractures  produced  by  the  small  caliber  bullet  have 
been  here  concisely  presented.  In  many  instances  photographs  have  been  substi- 
tuted for  drawings,  and  the  uses  of  plaster-of-Paris  as  a  splint-material  have  been 
more  fully  illustrated .  In  the  treatment  the  reader  is  not  only  told,  but  is  shown, 
how  to  apply  apparatus,  for  as  far  as  possible  all  the  details  are  illustrated.  This 
elaborate  and  complete  series  of  illustrations  constitutes  a  feature  of  the  book. 
There  are  645  of  them,  all  from  new  and  original  drawings  and  reproduced  in 
the  highest  style  of  art. 


PERSONAL  AND  PRESS  OPINIONS 

William  T.  Bull.  M.D.. 

Professor  of  Surgery,  College  of  Physicians  and  Surgeons,  New  York  City. 
"  The  work  is  a  good  one,  and  I  shall  certainly  recommend  it  to  students." 

Joseph  D.  BryaLnt,  M.D., 

Professor  of  the  Principles  aitd  Practice  of  Stcrgery,  University  and  Bellevue  Hospital 
Medical  College,  New  York  City. 
"  As  a  practical  demonstration  of  the  topic  it  is  excellent,  and  as  an  example  of  bookmaking  it 
is  highly  commendable." 

American  JournsLl  of  the  MediceLl  Sciences 

"  The  work  produces  a  favorable  impression  by  the  general  manner  in  which  the  subjsct  is 
treated.  Its  descriptions  are  concise  and  clear,  and  the  treatment  sound.  The  physical  examination  of 
the  injured  part  is  well  described,  and  .  .  .  the  method  of  making  these  examinations  is  illus- 
trated by  a  liberal  use  of  cuts." 


SAUNDERS'  BOOKS  ON 


9 

S 

Moderrv    S\irgery 

Modern  Surgery — General  and  Operative.  By  John  Chalmers 
DaCosta,  M.D.,  Professor  of  the  Principles  of  Surgery  and  of  Clini- 
cal Surgery  in  the  Jefferson  Medical  College,  Philadelphia  ;  Surgeon 
to  Philadelphia  Hospital  and  to  St.  Joseph's  Hospital,  Philadelphia. 
Handsome  octavo  volume  of  ii  17  pages,  copiously  illustrated. 

Cloth,  ^5.00  net ;  Sheep  or  Half  Morocco,  ^6.00  net. 


THIRD  REVISED  EDITION 

Enlarged  by  over  200  Pages,  with  over  100  New  Illustrations 

The  remarkable  success  attending  DaCosta' s  Manual  of  Surgery,  and  the 
general  favor  with  which  it  has  been  received,  have  led  the  author  in  this  revi- 
sion to  produce  a  complete  treatise  on  modern  surgery  along  the  same  lines  that 
made  the  former  editions  so  successful.  The  book  has  been  entirely  rewritten 
and  very  much  enlarged  in  this  edition.  It  has  been  increased  in  size  by  new 
matter  to  the  extent  of  over  200  pages,  and  contains  more  than  100  handsome 
neAv  illustrations,  making  a  total  of  439  beautiful  cuts  in  the  text.  The  old 
editions  of  this  excellent  work  have  long  been  favorites,  not  only  with  students 
and  teachers  but  also  with  practising  physicians  and  surgeons,  and  it  is  believed 
that  the  present  work,  presenting,  as  it  does,  the  latest  advances  in  the  science 
and  art  of  surgery,  will  find  an  even  wider  field  of  usefulness. 


OPINIONS  OF  THE  MEDICAL  PRESS 

The  Lancet,  London 

"  We  may  congratulate  Dr.  DaCosta  in  the  success  of  his  attempt.  .  .  .  We  can  recommend 
the  work  as  a  text-book  well  suited  to  students." 

The  Medical  Record,  New  York 

"  The  work  throughout  is  notable  for  its  conciseness.  Redundance  of  language  and  padding 
have  been  scrupulously  avoided,  while  at  the  same  time  it  contains  a  sufficient  amount  of  information 
to  fulfil  the  object  aimed  at  by  its  author— namely,  a  text-book  for  the  use  of  the  student  and  the 
busy  practitioner." 

American  Journal  of  the  Medical  Sciences 

"  The  author  has  presented  concisely  and  accurately  the  principles  of  modern  surgery.  The 
book  is  a  valuable  one,  which  can  be  recommended  to  students,  and  is  of  great  value  to  the  general 
practitioner." 


SURGER  V  ANT?  ANA  TO  MY 


McClellan's 
Art    Ana^tomy 

Anatomy  in  its  Relation  to  Art.  An  exposition  of  the  Bones 
and  Muscles  of  the  Human  Body,  with  Reference  to  their  Influence 
upon  its  Actions  and  external  Form.  By  George  McClellan,  M.D., 
Professor  of  Anatomy,  Pennsx'lv^ania  Academy  of  the  Fine  Arts. 
Handsome  quarto  volume,  9  by  11^  inches.  Illustrated  with  33S 
original  drawings  and  pliotographs,  with  260  pages  of  text. 

Dark  Blue  Vellum,  ^10.00  net;   Half  Russia,  $12.00  net. 

Jvist  Iss\ied 

This  is  an  exhaustive  work  on  the  structure  of  the  human  body  as  it  affects 
the  external  form,  and  although  especially  prepared  for  students  and  lovers  of 
art,  it  will  prove  very  valuable  to  all  interested  in  the  subject  of  anatomy.  It 
will  be  of  especial  .value  to  the  physician,  because  nowhere  else  can  he  find  si 
complete  a  consideration  of  surface  anatomy.  Those  interested  in  athletics  and 
physical  training  will  find  reliable  information  in  this  book. 

Howard  Pyle, 

In  the  Philadelphia  Medical  Journal. 
"  The  book  is  one  of  the  best  and  the  most  thorough  Text-books  of  artistic  anatomy  which  it  has 
been  the  writer's  fortune  to  fall  upon  and,  as  a  text-book,  it  ought  to  make  its  way  into  the  field  for 
which  it  is  intended." 

McClellan's 
R^egionaJ  Arva».tomy 

Regional  Anatomy  in  its  Relations  to  Medicine    and  Surgery. 

By  George  McClellan,  M.D.,  Professor  of  Anatomy,  Pennsylvania 
Academy  of  the  Fine  Arts.  Two  handsome  quartos,  884  pages  of  text ; 
97  full-page  chromolithographic  plates,  reproducing  the  author'  s  orig- 
inal dissections.  Cloth,  ^12.00  net;    Half  Russia,  ^15.00  net. 

Fourth  R.evised  Edition 

This  well-known  work  stands  without  a  parallel  in  anatomic  literature,  and  its 
remarkably  large  sale  attests  its  value  to  the  practitioner.  By  a  marvelous  series 
of  colored  lithographs  the  exact  appearances  of  the  dissected  parts  of  the  body 
are  reproduced,  enabling  the  reader  to  examine  the  anatomic  relations  with  as 
much  accuracy  and  satisfaction  as  if  he  had  the  actual  subject  before  him. 

British  Medical  Journal 

"The  illustrations  are  perfectly  correct  anatomical  studies,  and  do  not  reproduce  the  inaccura- 
cies which  experience  has  taught  us  to  look  for  in  works  of  a  similar  kind.  Some  of  the  plates, 
especially  those  of  the  anatomy  of  the  chest,  are  of  great  excellence." 


SAUNDERS'  BOOKS  ON 


GET  A  •  THE  NEW 

THE  BEST       >1L  n\  6  1*1  C  ©k.  rV        STANDARD 

Illustrdcted    Dictionocry 

SECOND  EDITION.  REVISED 

The    American    Illustrated    Medical    Dictionary.     A    New   and 

Complete  Dictionary  of  the  terms  used  in  Medicine,  Surgery,  Den- 
tistry, Pharmacy,  Chemistry,  and  kindred  branches  ;  together  with  new 
and  elaborate  tables  of  Arteries,  Muscles,  Nerves,  Veins,  etc.;  of 
Bacilli,  Bacteria,  Micrococci,  etc.;  Eponymic  Tables  of  Diseases, 
Operations,  Signs  and  Symptoms,  Stains,  Tests,  Methods  of  Treat- 
ment, etc.  By  W.  A.  N.  Dorland,  M.D.  Large  octavo,  770  pages. 
Flexible  leather,  ^$4.50  net;  with  thumb  index,  ^5.00  net. 

LARGE  FIRST  EDITION  EXHAUSTED  IN  EIGHT  MONTHS 

In  this  edition  the  book  has  been  subjected  to  a  thorough  revision.  The 
author  has  also  added  upward  of  one  hundred  important  new  terms  that  have 
appeared  in  medical  hterature  during  the  past  few  months. 

HowsLrd  A.  Kelly,  M.D., 

Professor  of  Gynecology,  Johns  Hopkins  University,  Baltbnore. 
"  Dr.  Dorland's  Dictionary  is  admirable.     It  is  so  well  gotten  up  and  of  such  convenient  size. 
No  errors  have  been  found  in  my  use  oi  it." 

Koswell  Pacrk,  M.D., 

Professor  of  Principles  and  Practice  of  Surgery  and  of  Clinical  Stirgery, 
University  of  Buffalo. 
"  I  must  acknowledge  my  astonishment  at  seeing  how  much  he  has  condensed  within  relatively 
small  space.     I  find  nothing  to  criticise,  very  much  to  commend,  and  was  interested  in  finding  some 
of  the  new  words  which  are  not  in  other  recent  dictionaries." 

American  Year-Book 

Saunders'    American    Year  =  Book    of    Medicine    and    Surgery. 

A  yearly  Digest  of  Scientific  Progress  and  Authoritative  Opinion  in  all 
branches  of  Medicine  and  Surgery,  drawn  from  journals,  monographs, 
and  text-books  of  the  leading  American  and  foreign  authors  and  inves- 
tigators. Arranged,  with  critical  editorial  comments,  by  eminent 
American  specialists,  under  the  editorial  charge  of  George  M.  Gould, 
A.M.,  M.D.  In  two  volumes  :  Vol.  I — General  Medicine,  octavo,  715 
pages,  illustrated  ;  Vol.  II — General  Surgery,  octavo,  684  pages,  illus- 
trated. Per  vol.:  Cloth,  ;^ 3. 00  net ;  Half  Morocco,  ^3.75  net.  Sold 
by  Subscription. 

In  these  volumes  the  reader  obtains  not  only  a  yearly  digest,  but  also  the 
invaluable  annotations  and  criticisms  of  the  editors.  As  usual,  this  issue  of  the 
Year-Book  is  amply  illustrated. 

The  Lancet,  London 

"  It  is  much  more  than  a  mere  compilation  of  abstracts,  for,  as  each  section  is  entrusted  to 
experienced  and  able  contributors,  the  reader  has  the  advantage  of  certain  critical  commentaries  and 
expositions    .    .    .    proceeding  from  writers  fully  qualified  to  perform  these  tasks." 


SURGER  V  AND  ANA  TOMY 


Helferich  aivd  Bloodgood's 
Fractures  and    Dislocations 

Atlas  and   Epitome  of   Traumatic    Fractures   and   Dislocations. 

By  Professor  Dr.  H.  Helferich,  Professor  of  Surgery  at  the  Royal 
University,  Greifswald,  Prussia.  Edited,  with  additions,  by  Joseph  C. 
Bloodgood,  M.D.,  Associate  in  Surgery,  Johns  Hopkins  University, 
Baltimore.  From  tlie  Fifth  Revised  and  Enlarged  German  Edition. 
With  216  colored  illustrations  on  64  lithographic  plates,  1 90  text- cuts, 
and  353  pages  of  text.      Cloth,  ^3.00  net.     In  Saunders"  Atlas  Series. 

A  Neu^  Volume — J\ist  Issued 

A  book  accurately  portraying  the  anatomic  relations  of  the  fractured  parts, 
together  with  the  diagnosis  and  treatment  of  the  condition,  has  become  an  abso- 
lute necessity.  This  work  is  intended  to  meet  all  requirements.  As  complete  a 
view  as  possible  of  each  case  has  been  presented,  thus  equipping  the  physician 
for  the  manifold  appearances  that  he  will  meet  with  in  practice.  The  illustra- 
tions are  unrivaled  for  accuracy  and  clearness  of  portrayal  of  the  conditions 
represented,  showing  the  visible  external  deformity,  the  X-ray  shadow,  the  ana- 
tomic preparation,  and  the  method  of  treatment. 


Zuckerkandl   aivd   DaCosta's 
Operoctive    Svirgery 

ADOPTED  BY  THE  U.  S.  AR.MY 

Atlas  and  Epitome  of  Operative  Surgery.  By  Dr.  O.  Zucker- 
kandl, of  Vienna.  Edited,  with  additions,  by  J.  Chalmers  DaCosta, 
M.D.,  Professor  of  the  Principles  of  Surgery  and  Clinical  Surgery,  Jef- 
ferson Medical  College,  Philadelphia.  40  colored  plates,  278  text-cuts,, 
and  410  pages  of  text.     Cloth,  ;^3.50  net.     In  Saunders'  Atlas  Series. 

SECOND  EDITION,  THOROVGHLY  REVISED  AND  GREATLY  ENLARGED 

In  this  new  edition  the  work  has  been  brought  precisely  down  to  date.  A 
number  of  chapters  have  been  practically  rewritten,  and  of  the  newer  operations, 
all  those  of  special  value  have  been  described.  Sixteen  valuable  lithographic 
plates  in  colors  and  sixty-one  text  figures  have  been  added,  thus  greatly  enhancing 
the  value  of  the  work. 

New  York  Medical  Journal 

"  We  know  of  no  other  work  upon  the  subject  in  which  the  illustrations  are  as  numerous  or  as- 
generally  satisfactory." 


lo  SAUNDERS'   BOOKS  ON 

MacdoivdLld's 
Diatgivosis  dtnd   TreaLtment 

A  Clinical  Text=Book  of  Surgical  Diagnosis  and  Treatment.    By 

J.  W.  Macdonald,  M.D.  Edin.,  F.R.C.S.  Edin.;  Professor  Emeritus 
of  the  Practice  of  Surgery  and  of  Clinical  Surgery  in  Hamline  Uni- 
versity, Minneapolis,  Minn.  Octavo,  798  pages,  handsomely  illus- 
trated. Cloth,  ;^5.00  net;  Sheep  or  Half  Morocco,  $6.00  net. 

This  work  aims  to  furnish  a  guide  to  surgical  diagnosis.  It  sets  forth  in  a 
systematic  way  the  necessity  of  examinations  and  the  proper  methods  of 
making  them.  The  various  portions  of  the  body  are  then  taken  up  in  order  and 
the  diseases  and  injuries  thereof  succinctly  considered  and  the  treatment  briefly 
indicated.  Practically  all  the  modern  and  approved  operations  are  described. 
The  work  concludes  with  a  chapter  on  the  use  of  the  Rontgen  rays  in  surgery. 

British  Medica.1  Journa.! 

"  Care  has  been  taken  to  lay  down  rules  for  a  systematic  and  comprehensive  examination  of 
■each  case  as  it  presents  itself,  and  the  most  advanced  and  approved  methods  of  clinical  investigation 
in  surgical  practice  are  fully  described." 

Wa-rren's 
PaLtKology  and  TKerapeutics 

Surgical  Pathology  and  Therapeutics.  By  John  Collins  War- 
ren, M.D.,  LL.D.,  F.R.C.S.  (Hon.),  Professor  of  Surgery,  Harvard 
Medical  School.  Octavo,  873  pages;  136  relief  and  lithographic 
illustrations,  33  in  colors.  With  an  Appendix  on  Scientific  Aids  to 
Surgical  Diagnosis  and  a  series  of  articles  on  Regional  Bacteriology. 
Cloth,  ;^5.oo  net;    Sheep  or  Half  Morocco,  ^$6.00  net. 

SECOND   EDITION,  WITH  AN  APPENDIX 

The  volume  is  for  the  bedside,  the  amphitheatre,  and  the  ward.  It  deals 
with  diseases  not  as  we  see  them  through  the  microscope  alone,  but  as  the  prac- 
titioner sees  their  effect  in  his  patients  ;  not  only  as  they  appear  in  and  affect 
culture-media,  but  also  as  they  influence  the  human  body  ;  and,  following  up 
the  demonstrations  of  the  nature  of  diseases,  the  author  points  out  their  logical 
treatment. 

R.oswell  PaLfk,  M.D., 

In  the  Harvard  Graduate  Magazine. 

"  I  think  it  is  the  most  creditable  book  on  surgical  pathology,  and  the  most  beautiful  medical 
illustration  of  the  bookmakers'  art  that  has  ever  been  issued  from  the  American  press." 


SURGER  V  AND  ANA  TOMY 


II 


Golebiewski  and  Bailey's 
Accidervt  Disea^ses 

Atlas  and  Epitome  of  Diseases  Caused    by  Accidents.     By  Dr. 

Ed.  Golebiewski,  of  Berlin.  Edited,  with  additions,  by  Pearce 
Bailey,  M.D.,  Attending  Physician  to  the  Almshouse  and  Incurable 
Hospitals,  New  York.  With  71  colored  figures  on  40  plates,  143  text- 
cuts,  and  549  pages  of  text.  Cloth,  $4.00  net.  In  Smuidcrs'  Hand- 
Atlas  Series. 

This  work  contains  a  full  and  scientific  treatment  of  the  subject  of  accident 
injury  ;  the  functional  disability  caused  thereby  ;  the  medicolegal  questions  in- 
volved, and  the  amount  of  indemnity  justified  in  given  cases.  The  work  is  in- 
dispensable to  every  physician  who  sees  cases  of  injury  due  to  accidents,  to  ad- 
vanced students,  to  surgeons,  and,  on  account  of  its  illustrations  and  statistical 
data,  it  is  none  the  less  useful  to  accident  insurance  organizations. 

The  Medical  Record,  New  York 

"  This  volume  is  upon  an  important  and  only  recently  systematized  subject,  which  is  growing  in 
extent  all  the  time.     The  pictorial  part  Of  the  book  is  very  satisfactory." 

Sulte^rv  ©^.n^d  Coley's 
Abdomin.^  HerrvioLS 

Atlas  and  Epitome  of  Abdominal  Hernias.  By  Privatdocent 
Dr.  Georg  Sultan,  of  Gottingen.  Edited,  with  additions,  by  Wil- 
liam B.  CoLEY,  M.D.,  Clinical  Lecturer  on  Surgery,  Columbia  Univer- 
sity (College  of  Physicians  and  Surgeons).  With  119  illustrations, 
36  of  them  in  colors,  and  277  pages  of  text.  Cloth,  $3.00  net. 

In  Saunders'  Hand- Atlas  Series. 

During  the  last  decade  the  operative  side  of  this  subject  has  been  steadily 
growing  in  importance,  until  now  it  is  absolutely  essential  to  have  a  book  treat- 
ing of  its  surgical  aspect.  This  present  atlas  does  this  to  an  admirable  degree. 
The  illustrations  are  not  only  very  numerous,  but  they  portray  most  accurately 
the  conditions  represented. 

Robert  H.  M.  DawbaLrn,  M.D., 

Professor  of  Surgery  and  of  Surgical  Anatomy,  New  York  Polyclinic. 

"  I  have  spent  several  interesting  hours  over  it  to-day,  and  shall  willingly  recommend  it  to  my 
classes  at  the  Polyclinic  College  and  elsewhere." 


SAUNDERS'  BOOKS  ON 


Grant's  Surgery  of 
Face,  Mouth,  and  Jaws 

A  Text=Book  of  the  Surgical  Principles  and  Surgical  Diseases  of 
the  Face,  Mouth,  and  Jaws.  For  Dental  Students.  By  H.  Horace 
Grant,  A.M.,  M.D.,  Professor  of  Surgery  and  of  Clinical  Surgery, 
Hospital  College  of  Medicine ;  Professor  of  Oral  Surgery,  Louisville 
College  of  Dentistry,  Louisville.  Octavo  volume  of  231  pages,  with 
68  illustrations.  Cloth,  ;^2.5o  net. 

FOR-  DENTAL  STUDENTS 

This  text-book,  designed  for  the  student  of  dentistry,  succinctly  explains  the 
principles  of  dental  surgery  applicable  to  all  operative  procedures,  also  discussing 
such  surgical  lesions  as  are  likely  to  require  diagnosis  and  perhaps  treatment  by 
the  dentist.  Whenever  necessary,  for  the  better  elucidation  of  the  text,  well- 
selected  illustrations  have  been  employed.  For  the  dental  student  the  work  will 
be  found  an  invaluable  text-book,  and,  indeed,  the  medical  beginner  also  will 
find  its  perusal  of  more  than  passing  benefit. 

Robson  dLivd  MoyiviKaLiv 
on  tKe  Pa^rvcrescs 

Diseases  of  the  Pancreas  and  Their  Surgical  Treatment.     By 

A.  W.  Mayo  Robson,  F.R.C.S.,  Senior  Surgeon,  Leeds  General  Infir- 
mary ;  Emeritus  Professor  of  Surgery,  Yorkshire  College,  Victoria  Uni  ■ 
versity,  England ;  and  B.  G.  A.  Moynihan,  M.S.  (Lond.),  F.R.C.S., 
Assistant  Surgeon,  Leeds  General  Infirmary  ;  Consulting  Surgeon  to 
the  Skipton  and  to  the  Mirfield  Memorial  Hospitals,  England.  Octavo 
of  293  pages,  illustrated.  Cloth,  ^^3.00  net. 

JUST  ISSUED 

This  work,  dealing  with  the  surgical  aspect  of  pancreatic  disease,  has  been 
written  with  a  two-fold  object :  to  record  and  to  review  the  work  done  in  the  past, 
and  to  indicate,  so  far  as  possible,  the  scope  and  trend  of  future  research.  Besides 
containing  a  very  commendable  exposition  of  the  various  diseases  and  injuries  of 
the  pancreas,  the  volume  includes  an  accurate  account  of  the  anatomy,  abnor- 
malities, development,  and  structure  of  the  gland. 


SURGER  V  AND  ANA  TOMY  1 3 

Servrv's  T\xmors 

Pathology  and  Surgical  Treatment  of  Tumors.  By  Nicholas 
Senn,  M.D.,  Ph.D.,  LL.D.,  Professor  of  Surgery,  Rush  Medical  Col- 
lege, Chicago.  Handsome  octav^o,  718  pages,  with  478  engravings, 
including  12  full-page  colored  plates. 

Cloth,  ;^5.oo  net ;  Sheep  or  Half  Morocco,  $6.00  net. 

SECOND  EDITION.  REVISED 

Books  specially  devoted  to  this  important  subject  are  few,  and  in  our  text- 
books and  systems  of  surgery  this  part  of  surgical  pathology  is  usually  condensed 
to  a  degree  incompatible  with  its  scientific  and  clinical  importance.  The  author 
spent  many  years  in  collecting  the  material  for  this  work,  and  has  taken  great 
pains  to  present  it  in  a  manner  that  should  prove  useful  as  a  text-book  for  the 
student,  a  work  of  reference  for  the  general  practitioner,  and  a  reliable,  safe  guide 
for  the  surgeon. 

Journa.1  of  the  AmericaLiv  Medical  AssocIa.tion 

"  The  most  exhaustive  of  any  recent  book  in  English  on  this  subject.  It  is  well  illustrated,  and 
will  doubtless  remain  as  the  principal  monograph  on  the  subject  in  our  language  for  some  years. 
The  author  has  given  a  notable  and  lasting  contribution  to  surgery." 


Stor\.ey*s 
Sxirgica.!  TecKivic  for  N\irses 

Surgical  Technic  for  Nurses.  By  Emily  A.  M.  Stoney,  Super- 
intendent of  the  Training  School  for  Nurses  at  the  Carney  Hospital, 
South  Boston.      i2mo,  200  pages,  profusely  illustrated. 

Cloth,  $1.25  net. 

The  work  is  intended  as  a  modern  text-book  on  Surgical  Nursing  in  both 
hospital  and  private  practice.  The  first  part  of  the  book  is  devoted  to  Bacteri- 
ology and  Antiseptics  ;  the  second  part  to  Surgical  Technic,  Signs  of  Death,  and 
Autopsies.  The  matter  in  the  book  is  presented  in  a  practical  form,  and  will 
prove  of  value  to  all  nurses  who  are  called  upon  to  attend  surgical  cases. 

Tra.iiYed  Nurse  and  Hospital  Review 

"  These  subjects  are  treated  most  accurately  and  up  to  date,  without  the  superfluous  reading 
which  is  so  often  employed.  .  .  .  Nurses  will  find  this  book  of  the  greatest  value  both  during 
their  hospital  course  and  in  private  practice." 


14  SAUNDERS'  BOOKS  ON 

He^ynes'  Anactomy 

A  Manual  of  Anatomy.  By  Irving  S.  Haynes,  M.D.,  Professor 
of  Practical  Anatomy,  Cornell  University  Medical  College.  Octavo, 
680  pages,  illustrated  with  42  diagrams  and  134  full-page  half-tones 
from  photographs  of  the  author's  dissections.  Cloth,  ^2.50  net. 

In  this  book  the  great  practical  importance  of  a  thorough  knowledge  of  the 
viscera  and  of  their  relations  to  the  surface  of  the  body  has  been  recognized  by 
according  to  them  a  prominent  place  in  illustration  and  description. 

The  Medical  Record,  New  York 

"This  book  is  the  work  of  a  practical  instructor — one  who  knows  by  experience  the  require- 
ments of  the  average  student,  and  is  able  to  meet  these  requirements  in  a  very  satisfactory  way.  The 
book  is  one  that  can  be  commended." 

Beck's  Fractures 

Fractures.  By  Carl  Beck,  M.D.,  Professor  of  Surgery,  New- 
York  Post-graduate  Medical  School  and  Hospital.  With  an  Appendix 
on  the  Practical  Use  of  the  Rontgen  Rays.  335  pages,  170  illus- 
trations. Cloth,  1^3.50  net. 

In  this  book  particular  attention  is  devoted  to  the  Rontgen  rays  in  diagnosis. 
The  work  embodies  in  a  systematic  treatise  the  important  essentials  of  this  sub- 
ject, based  on  the  extensive  experience  of  the  author  in  X-ray  work. 

The  Medical  Record,  New  York 

"  The  use  of  the  rays  with  its  technic  is  full}'  explained,  and  the  practical  points  are  brought  out 
with  a  thoroughness  that  merits  high  praise." 

AmericaLiv  Pocket  Dictioivary 

The  American  Pocket  Medical  Dictionary.  Edited  by  W.  A. 
Newman  Borland,  A.M.,  M.D.,  Assistant  Obstetrician,  Hospital  of 
the  University  of  Pennsylvania,  etc.  518  pages.  Full  leather,  limp, 
with  gold  edges,  ^i.oo  net;  with  patent  thumb  index,  ^1.25  net. 

THIRD  EDITION,  REVISED 

This  is  an  absolutely  new  book.  It  is  complete,  defining  all  the  terms  of 
modern  medicine,  and  forming  an  unusually  full  vocabulary.  It  makes  a  special 
feature  of  the  newer  words  and  contains  a  wealth  of  anatomical  tables. 

JaLmes  W.  Holl&nd,  M.D., 

Professor  of  Medical  Cheinistry  and  Toxicology,  and  Dean,  Jefferson  Medical 
College,  Philadelphia. 
"  I  am  struck  at  once  with  admiration  at  the  compact  size  and  attractive  exterior.    I  can  recom- 
mend it  to  our  students  without  reserve." 


SURGER  Y  AND  ANA  TOMY 


15 


Warwick  and  Tunstall's  First  Aid 

First  Aid  to  the  Injured  and  Sick.  By  F.  J.  Warwick,  B.A.,  M.B. 
Cantab.,  Associate  of  King's  College,  London  ;  and  A.  C.  Tunstall,  M.D., 
F.R.C.S.  Edin.,  Surgeon-Captain  Commanding  the  East  London  Volunteer 
Brigade  Bearer  Company.      i6mo  of  232  pages  and  nearly  200  illustrations. 

Cloth,  gi.oo  net. 

"  Contains  a  great  deal  of  valuable  information  well  and  tersely  expressed.  It  will  prove 
especially  useful  to  the  volunteer  first  aid  and  hospital  corps  men  of  the  National  Guard."— 
Journal  American  Medical  Association. 

Beck's  S\irgical  Asepsis 

A  Manual  of  Surgical  Asepsis.  By  Carl  Beck,  M.D.,  Professor  of  Sur- 
gery, New  York  Post-graduate  Medical  School  and  Hospital.  306  pages  ;  65 
text-illustrations  and  12  full-page  plates.  Cloth,  $1.25  net. 

"  The  book  is  well  written.  The  data  are  clearly  and  concisely  given.  The  facts  are  well 
arranged.  It  is  well  worth  reading  to  the  student,  the  physician  in  general  practice,  and  the 
surgeon." — Boston  Medical  and  Surgical  Journal. 

Pye's  Bandaging 

Elementary  Bandaging  and  Surgical  Dressing.  With  Directions  con- 
cerning the  Immediate  Treatment  of  Cases  of  Emergency.  By  Walter 
Pye,  F.R.C.S.,  late  Surgeon  to  St.  Mary's  Hospital,  London.  Small  i2mo, 
over  80  illustrations.  Cloth,  flexible  covers,  75  cts.  net. 

"  The  author  writes  well,  the  diagrams  are  clear,  and  the  book  itself  is  small  and  portable, 
although  the  paper  and  type  are  good." — British  Medical  Journal. 

Senn's  Syllabus  of  Surgery 

A  Syllabus  of  Lectures  on  the  Practice  of  Surgery.  Arranged  in  con- 
formity with  ' '  American  Text-Book  of  Surgery. ' '  By  Nicholas  Senn, 
M.D.,  Ph.D.,  LL.D.,  Professor  of  Surgery,  Rush  Medical  College,  Chicago. 

Cloth,  $1.50  net. 

"  The  author  has  evidently  spared  no  pains  in  making  his  Syllabus  thoroughly  comprehensive, 
and  has  added  new  matter  and  alluded  to  the  most  recent  authors  and  operations.  Full  refer- 
ences are  also  given  to  all  requisite  details  of  surgical  anatomy  and  pathology."— .g?-z?wA  Medi- 
cal Journal. 

Keen's  Operation  Blank,  Second  Edition,  Revised  Form 
An  Operation  Blank,  with  Lists  of  Instruments,  etc..  Required  in  Various 
Operations.  Prepared  by  Wm.  W.  Keen,  M.D.,  LL.D.,  F.R.C.S.  (Hon.),  Pro- 
fessor of  the  Principles  of  Surgery  and  of  Clinical  Surgery,  Jefferson  Medical 
College,  Philadelphia.     Price  per  pad,  blanks  for  fifty  operations,  50  cts.  net. 

"  Will  serve  a  useful  purpose  for  the  surgeon  in  reminding  him  of  the  details  of  preparation  for 
the  patient  and  the  room  as  well  as  for  the  instruments,  dressings,  and  antiseptics  needed." 
— New  York  Medical  Record. 

Keen  on  tKe  Surgery  of  TypKoid 

The  Surgical  Complications  and  Sequels  of  Typhoid  Fever.     By  Wm.  W. 

Keen,  M.D.,  LL.D.,  F.R.C.S.  (Hon.),  Professor  of  the  Principles  of  Surgery 
and  of  Clinical  Surgery,  Jefferson  Medical  College,  Philadelphia,  etc. 
Octavo  volume  of  386  pages,  illustrated.  Cloth,  ^3.00  net. 

"  Every  surgical  incident  which  can  occur  during  or  after  typhoid  fever  is  amply  discussed  and 
fully  illustrated  by  cases.  .  .  .  The  book  will  be  useful  both  to  the  surgeon  and  physician." — 
The  Practitioner y  London. 


l6  SURGER  Y  AND  ANA  TOMY 

Moore's  Orthopedic  Surgery 

A  Manual  of  Orthopedic  Surgery.     By  James  E.  Moore,  M.D.,  Professor 

of  Clinical  Surgery,  University  of  Minnesota,  College  of  Medicine  and  Surgery. 

Octavo  of  356  pages,  handsomely  illustrated.  Cloth,  ^2.50  net. 

"  The  book  is  eminently  practical.  It  is  a  safe  guide  in  the  understanding-  and  treatment  of 
orthopedic  cases.     Should  be  owned  by  every  surgeon  and  practitioner." — Annals  of  Surgery. 

Nancrede's   Anatomy  and   Dissection.     Editroa 

Essentials    of    Anatomy   and    Manual    of   Practical    Dissection.      By 

Charles  B.  Nancrede,  M.D.,  Professor  of  Surgery  and  of  Clinical  Surgery, 

University  of  Michigan,  Ann  Arbor.     Post-octavo  ;   500  pages,  with  full-page 

lithographic  plates  in  colors,  and  nearly  200  illustrations. 

Extra  Cloth  (or  Oilcloth  for  the  dissecting-room),  ^2.00  net. 

"  The  plates  are  of  more  than  ordinary  excellence,  and  are  of  especial  value  to  students  in  their 
work  in  the  dissecting-room."— yoM»'«a/  of  the  American  Medical  Association. 

Nancrede's  Principles  of  Surgery 

Lectures  on  the  Principles  of  Surgery.  By  Chas.  B.  Nancrede,  M.D., 
LL.D.,  Professor  of  Surgery  and  of  Clinical  Surgery,  University  of  Michigan, 
Ann  Arbor.     Octavo,  398  pages,  illustrated.  Cloth,  $2.50  net. 

"  We  can  stronglj'  recommend  this  book  to  all  students  and  those  who  would  see  something 
of  the  scientific  foundation  upon  which  the  art  of  surgery  is  built." — Quarterly  Medical  Journal, 
Sheffield,  England. 

Nancrede's  Essentials  of  Anatomy.  ^'^Edmon^^*^ 

Essentials  of  Anatomy,  including  the  Anatomy  of  the  Viscera.     By  Chas. 

B.  Nancrede,  M.D.,  Professor  of  Surgery  and  of  Clinical  Surgery,  University 

of  Michigan,  Ann  Arbor.     Crown  octavo,  388  pages  ;   180  cuts.     With  an 

Appendix  containing  over  60  illustrations  of  the  osteology  of  the  body.     Based 

Gw  Gray  s  Anatomy .         Cloth,  $1.00  net.     In  Saunders    Question  Compends. 

"  The  questions  have  been  wisely  selected,  and  the  answers  accurately  and  concisely  given." — 
University  Medical  Magazi7ie. 

Martin's  Essentials  of   Surgery.     ^^"'^Revifed*'"'" 

Essentials  of  Surgery.  Containing  also  Venereal  Diseases,  Surgical  Land- 
marks, Minor  and  Operative  Surgery,  and  a  complete  description,  with  illus- 
trations, of  the  Handkerchief  and  Roller  Bandages.  By  Edward  Martin, 
A.M.,  M.D.,  Professor  of  Clinical  Surgery,  University  of  Pennsylvania,  etc. 
Crown  octavo,  338  pages,  illustrated.  With  an  Appendix  on  Antiseptic  Sur- 
gery, etc.  Cloth,  $1.00  net.     In  Sannders'  Question  Compends. 

"  Written  to  assist  the  student,  it  will  be  of  undoubted  value  to  the  practitioner,  containing  as  it 
does  the  essence  of  surgical  work." — Boston  Medical  and  Surgical  Journal. 

Martin's   Essentials  of  Minor  Surgery,  Band- 
aging,   and   Venereal    Diseases.       ^^*'°gdi{k,n'''^^'^ 

Essentials  of  Minor  Surgery,  Bandaging,  and  Venereal  Diseases.    By 

Edward  Martin,  A.M.,  M.D.,  Professor  of  Clinical  Surgery,  University  of 

Pennsylvania,  etc.   Crown  octavo,  166  pages,  with  78  illustrations. 

Cloth,  $1.00  net.     /«  Satinders'  Question  Compejids. 

"The  best  condensation  of  the  subjects  of  which  it  treats  yet  placed  before  the  profession." — 
The  Medical  News,  Philadelphia. 


^^^^U^BM    UNIVERSITY 

Provided  bylu  ?^^^"te  period  af'  '"^^^^^ed  beJow  o 
;^;=========^^  ^^^ang-ement  with 

^^E  BORROWED  /^^====^~_ 


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COLUMBIA  UNIVERSITY  LIBRARIES  (hsi.stx) 

RD  631  MS?  1903  C.I 

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